Adverse Benefits Determination definition

Adverse Benefits Determination means any denial, reduction or termination of Benefits by Delta Dental for which a Claim has been filed.
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Adverse Benefits Determination means any denial of a request for benefits or any rescission or termination of benefits, in each case in whole or in part, all as more specifically described in the Department of Labor regulations, specifically, 29 C.F.R. § 2560.503-7(m)(4).
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Adverse Benefits Determination means any denial, reduction or termination of Benefits by
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Examples of Adverse Benefits Determination in a sentence

  • This is considered an Adverse Benefits Determination and the written notice must include the reasons for not recommending CLIP and an outline of recommendations for alternative less restrictive services for the youth.

  • An appeal of an Adverse Benefits Determination must be made in writing within 180 days upon receipt of the notice that the claim was denied.

  • If the Claimant’s request for external review is complete but the Final Internal Adverse Benefits Determination is not eligible for external review, the notice must state the reasons for ineligibility and include contact information for Employee Benefits Security Administration of the Department of Labor.

  • The Claimant, or the Claimant’s Authorized Representative, may request access to all relevant documents in order to evaluate whether to request review of an Adverse Benefits Determination and if review is requested, to prepare for such review.

  • If an appeal is not made within the above referenced timeframe all rights to appeal the Adverse Benefits Determination and to file suit in court will be forfeited.

  • Any such written request for review must be delivered to the Administrator not later than one hundred eighty (180) days after the date the Claimant receives written notification of the Adverse Benefits Determination or from the date the Claimant was deemed to have received an Adverse Benefits Determination for such claim.

  • The review of the Adverse Benefits Determination will take into account all new information, whether or not presented or available at the initial determination.


More Definitions of Adverse Benefits Determination

Adverse Benefits Determination means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of any of the following:
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Related to Adverse Benefits Determination

  • Adverse Benefit Determination means any of the following:

  • Administrative merits determination means certain notices or findings of labor law violations issued by an enforcement agency following an investigation. An administrative merits determination may be final or be subject to appeal or further review. To determine whether a particular notice or finding is covered by this definition, it is necessary to consult section II.B. in the DOL Guidance.

  • Final Adverse Benefit Determination means an adverse benefit determination that is upheld at the completion of a health plan issuer’s internal appeals process.

  • 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.

  • Self-Determination means a philosophy and process by which individuals with developmental disabilities are empowered to gain control over the selection of support services that meet their needs. The basic principles of self-determination are:

  • Claim Determination Period means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

  • Disability benefit recipient means a member who is receiving a disability benefit.

  • Eligibility Determination means an approval or denial of eligibility and a renewal or termination of eligibility as set forth in OAR 410-200-0015;¶

  • Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment).

  • Adverse determination shall have the meaning set forth in Section 19.7.

  • Event Determination Date means either:

  • Disability benefits means any cash payments which are payable to a covered individual for all or part of a period of disability pursuant to P.L.1948, c.110 (C.43:21-25 et al.).

  • Specific learning disability (SLD) means a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia.

  • Child custody determination means a judgment, decree, or other order of a court providing for the legal custody, physical custody, or visitation with respect to a child. The term includes a permanent, temporary, initial, and modification order. The term does not include an order relating to child support or other monetary obligation of an individual.

  • SOFR Determination Date has the meaning specified in the definition of “Daily Simple SOFR”.

  • specific learning disabilities means a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia;

  • Flood Elevation Determination means a determination by the Administrator of the water surface elevations of the base flood, that is, the flood level that has a one percent or greater chance of occurrence in any given year.

  • Final Determination Date means the following:

  • Adverse employment action means an action that affects an em- ployee ’s compensation, promotion, transfer, work assignment, or performance evaluation, or any other employment action that would dissuade a reasonable employee from making or supporting a report of abuse or neglect under Family Code 261.101.

  • Determination of Taxability means and shall be deemed to have occurred on the first to occur of the following: