Adverse Benefit Determination. An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
Adverse Benefit Determination. The denial or limited authorization of a requested service, including determinations on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; the reduction, suspension, or termination of a previously authorized services; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by the Division; the failure of the Contractor to act within the timeframes provided in 42 C.F.R. § 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals; for residents in a rural area with only one MCO, the denial of an enrollee’s request to exercise his or her right, under 42 C.F.R. § 438.52(b)(2)(ii); the denial of an enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities; and determinations by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determinations made by a State with regard to the preadmission screening and annual resident review requirements of Section 1919(e)(7) of the Act, if applicable.
Adverse Benefit Determination. (i) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a Covered Service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv) the failure to provide services in a timely manner; (v) the failure of the Contractor to act within the required timeframes for the standard resolution of Grievances and Appeals; (vi) for a resident of a rural area with only one Contractor, the denial of an Enrollee’s request to obtain services outside of the Network; or (vii) the denial of an Enrollee’s request to dispute a financial liability.
Adverse Benefit Determination. (i) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a Covered Service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv) the failure to provide services in a timely manner, as defined by the State; (v) the failure of the ICO to act within the required timeframes for the standard resolution of Grievances and Appeals; (vi) for a resident of a rural area with only one ICO, the denial of an Enrollee’s request to obtain services outside of the Network; or (vii) the denial of an Enrollee’s request to dispute a financial liability.
Adverse Benefit Determination. An Adverse Benefit Determination is a determination, including a Claim denial, by or on behalf of Community Health Options® (“Health Options”), any (1) Adverse Health Care Treatment Decision, or (2) denial reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a Benefit, including an action based on a determination of a Member’s ineligibility to participate in the Plan. Adverse Health Care Treatment Decision. A health care treatment decision made by or on behalf of Health Options denying in whole or in part payment for or provision of otherwise Covered Services requested by or on behalf of a Member. Adverse Health Care Treatment Decisions include rescission determinations and initial coverage eligibility determinations as provided under federal law. Adverse Utilization Determination. A determination by Health Options that: (1) an admission, availability of care, continued stay, or other health care service has been reviewed and does not meet Health Options’ requirements for Medical Necessity, appropriateness, health care setting, level of care or effectiveness; and (2) payment for the requested services is therefore denied, reduced without further opportunity for additional service, or terminated.
Adverse Benefit Determination. Any one of the following actions or inactions by the Contractor:
Adverse Benefit Determination. Except for non-payment, we will not contest this policy after it has been in force for a period of two years from the later of the plan effective date or latest reinstatement date.
Adverse Benefit Determination. We will reimburse the lesser of the provider’s charges or the maximum benefit amount shown in the Summary of Medical Benefits.
Adverse Benefit Determination. An adverse benefit determination means: (1) whether or not a service is a Covered Service; (2) the denial or limited authorization of a requested service, including the type or level of service; (3) the reduction, suspension, or termination of a previously authorized service; (4) the denial, in whole or in part, of payment of a service; (5) the failure to provide or authorize services within a timely manner, as defined Section 2.12.C.ii of this Agreement (6) the failure of the Contractor to act within the timeframes required by the Rhode Island Medicaid Managed Care Grievance and Appeals Process of this Agreement or (7) the denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. A Notice of Adverse Benefit Determination must be in writing and must explain: • The action that the Contractor, or its agents, has taken or intends to take. • The reasons for the adverse benefit determination, including the right of the member to be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The member’s or provider’s right to file an appeal with the Contractor, including information on exhausting the Contractor’s one level of appeal, the right to an external appeal (medical review), and the right to request a State Fair Hearing. • The procedures for exercising the rights in this section. • The circumstances under which expedited appeal resolution is available and how to request it. • The member’s rights to have covered benefits continue pending resolution of the appeal and the final decision of XXXXX. How to request that benefits be continued and the circumstances, consistent with state policy, under which the members may be required to pay the costs of these services. The Contractor may mail notice of adverse benefit determination on the date of the action when: • The Contractor has factual information confirming the death of the member; • The member submits a signed written statement requesting service termination; • The member submits a signed written statement including information that requires service termination or reduction and indicates that he or she understands that service t...
Adverse Benefit Determination. An Adverse Benefit Determination is a determination, including a Claim denial, by or on behalf of Community Health Options® (“Health Options”), any (1) Adverse Health Care Treatment Decision, or (2) denial reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a Benefit, including an action based on a determination of a Member’s ineligibility to participate in the Plan. An Adverse Benefit Determination may also include an administrative denial. Examples of an administrative denial are: Prior Approval requests that are made by ineligible facilities (lacking appropriate accreditation), benefit limits being exhausted, non-plan providers seeking Prior Approval, or a Provider’s failure to obtain Prior Approval in a timely fashion.
