Final Internal Adverse Benefit Determination definition

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX’s internal review/appeal process.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by HMO at the completion of HMO’s internal review/appeal process.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator or, if applicable, your Employer, at the completion of the internal review/appeal process of an Adverse Benefit Determination with respect to which the internal review/appeal process has been deemed exhausted.

Examples of Final Internal Adverse Benefit Determination in a sentence

  • The Claim Administrator must provide or transmit all necessary documents and information considered in making the Adverse Benefit Determination or Final Internal Adverse Benefit Determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method.

  • If the Claim Administrator fails to timely provide the documents and information, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Benefit Determination or Final Internal Adverse Benefit Determination.

  • The external review may be terminated as a result of the reconsideration only if the Claim Administrator decides, upon completion of its reconsideration, to reverse the Adverse Benefit Determination or Final Internal Adverse Benefit Determination and provide coverage or payment.

  • The IRO is not required to, but may, accept and consider additional information submitted after 10 business days.c. Within five business days after the date of assignment of the IRO, the Claim Administrator must provide to the assigned IRO the documents and any information considered in making the Adverse Benefit Determination or Final Internal Adverse Benefit Determination.

  • Upon receipt of any such information, the Claim Administrator may reconsider the Adverse Benefit Determination or Final Internal Adverse Benefit Determination that is the subject of the external review.


More Definitions of Final Internal Adverse Benefit Determination

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator or your Employer at the completion of the Claim Administrator's or Employer's internal review/appeal process.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the conclusion of the internal claims and appeals process, or an Adverse Benefit Determination with respect to which the internal claims and appeals process has been deemed exhausted.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by Blue Cross and Blue Shield at the completion of the Blue Cross and Blue Shield's internal review/appeal process.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by Us at completion of Our internal review/appeal process.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator at the completion of the Claim Administrator's internal review/appeal process.
Final Internal Adverse Benefit Determination means an adverse benefit determination that has been upheld by a health plan or carrier at the completion of the internal appeals process, or an adverse benefit determination with respect to which the internal appeals process has been exhausted under the exhaustion rules described in RCW 48.43.530 and 48.43.535.
Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the completion of the internal review/appeal process.