Notice of Adverse Benefit Determination definition

Notice of Adverse Benefit Determination means the notice must meet all requirements found at 42 CFR 438.44
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Notice of Adverse Benefit Determination means a written notice provided to the Member that explains the reasons for the Adverse Benefit Determination made by the AdSS regarding the service authorization request and includes the information required by this Policy.
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Examples of Notice of Adverse Benefit Determination in a sentence

  • The Contractor is required send out a Notice of Adverse Benefit Determination to the Enrollee and the Provider on the day that the timeframe expires.

  • A Notice of Adverse Benefit Determination is also used to tell you if your grievance, appeal, or expedited appeal was not resolved in time, or if you did not get services within the mental health plan’s timeline standards for providing services.

  • The Contractor shall provide a Notice of Adverse Benefit Determination to the Aggrieved Person at the time the Contractor determines the timeframe for resolving the Appeal or Grievance will not be met.

  • A Notice of Adverse Benefit Determination is a letter that your mental health plan will send you if it makes a decision to deny, limit, reduce, delay, or end services you and your provider believe you should get.

  • A Notice of Adverse Benefit Determination is also used to tell you if your grievance, appeal, or expedited appeal was not resolved in time, or if you didn’t get services within the Drug Medi-Cal Organized Delivery System county’s timeline standards for providing services.

  • The Contractor shall provide a Notice of Adverse Benefit Determination to the Enrollee at the time either the Enrollee or provider informs the Contractor that the provider failed to meet the performance benchmarks for appointment waiting times found in Article 10.2.6.

  • You have a right to receive a written Notice of Adverse Benefit Determination.

  • The Aggrieved Person may request an expedited Appeal within 60 calendar days from the date on the Contractor’s written Notice of Adverse Benefit Determination.

  • The Contractor shall provide a Notice of Adverse Benefit Determination to the Enrollee at the time either the Enrollee or Provider informs the Contractor that the Provider failed to meet the performance standards for offering face-to- face appointment waiting times found in Article 10.4.

  • The Aggrieved Person may request an oral or written Appeal within 60 calendar days from the date on the Contractor’s written Notice of Adverse Benefit Determination.

Related to Notice of Adverse Benefit Determination

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

  • Adverse Benefit Determination means any of the following:

  • 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.

  • 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.

  • Final Adverse Determination means an Adverse Determination involving a Covered Service that has been upheld by Blue Cross and Blue Shield or its designated utilization review organization, at the completion of Blue Cross and Blue Shield's internal grievance process procedures.

  • 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.

  • Expert Determination the process described in Paragraph 6 of Schedule 8.3 (Dispute Resolution Procedure);

  • Determination Notice is defined in Section 6.1(b)(i) of the Agreement.

  • Expected Claim Notice means a notice that, as a result of a legal proceeding instituted by or written claim made by a third party, an Indemnified Party reasonably expects to incur Damages for which it is entitled to indemnification under Article VI.

  • 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.

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

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

  • Event Determination Date means either:

  • Reset Determination Date means, in respect of the First Reset Period, the second Business Day prior to the First Reset Date, in respect of the first Subsequent Reset Period, the second Business Day prior to the Second Reset Date and, in respect of each Subsequent Reset Period thereafter, the second Business Day prior to the first day of each such Subsequent Reset Period;

  • ABR Term SOFR Determination Day has the meaning specified in the definition of “Term SOFR”.

  • Company Adverse Recommendation Change shall have the meaning set forth in Section 5.3(c).

  • Monthly Report Determination Date The meaning specified in Section 10.7(a).

  • Adverse decision means a decision reducing,

  • Base Rate Term SOFR Determination Day has the meaning specified in the definition of “Term SOFR”.

  • Distribution Determination Date means, in respect of any Distribution Period, that number of business days prior thereto as is set out in the applicable Pricing Supplement or on the face of the relevant Perpetual Security;

  • Periodic Term SOFR Determination Day has the meaning specified in the definition of “Term SOFR”.

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

  • Payment Determination Date means, with respect to any Payment Date, one (1) Business Day immediately preceding such Payment Date.

  • Interest Determination Date means, with respect to a Rate of Interest and Interest Accrual Period, the date specified as such hereon or, if none is so specified, (i) the first day of such Interest Accrual Period if the Specified Currency is Sterling or (ii) the day falling two Business Days in London for the Specified Currency prior to the first day of such Interest Accrual Period if the Specified Currency is neither Sterling nor euro or (iii) the day falling two TARGET Business Days prior to the first day of such Interest Accrual Period if the Specified Currency is euro.

  • Term SOFR Determination Day has the meaning assigned to it under the definition of Term SOFR Reference Rate.