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, 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. (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 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 ICOMedicare-Medicaid Plan, the denial of an Enrollee’s request to obtain services outside of the NetworkService Area; 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 Contractor to act within the required timeframes for the standard resolution of Grievances and Appeals; (vi) for a resident Resident of a rural area with only one ICODemonstration Plan, the denial of an Enrollee’s request to obtain services outside of the Networknetwork; 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 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 ICODemonstration Plan, the denial of an Enrollee’s request to obtain services outside of the Networknetwork; 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 STAR+PLUS MMP 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 ICOSTAR+PLUS MMP, 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.