Common use of Adverse Benefit Determination Clause in Contracts

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.