Common use of Adverse Benefit Determination Clause in Contracts

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; (v) the failure of the Contractor CICO to act within the required timeframes for and the standard resolution of Grievances and Appeals; (vi) for a resident of a rural area with only one ContractorCICO, 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; (v) the failure of the Contractor ICDS Plan 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 ContractorICDS Plan, the denial of an Enrolleea Beneficiary’s request to obtain services outside of the Networknetwork; or (vii) the denial of an EnrolleeBeneficiary’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 necessityMedical 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 CICO to act within the required timeframes for and the standard resolution of Grievances and Appeals; (vi) for a resident of a rural area with only one ContractorCICO, 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.