Common use of Adverse Action Clause in Contracts

Adverse Action. (i) The denial or limitation of authorization of a requested service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial of payment for a service; (iv) the failure to provide services in a timely manner; (v) the failure to respond to an Appeal in a timely manner, or (vi) solely with respect to an Demonstration Plan that is the only Contractor serving a rural area, the denial of an Enrollee’s request to obtain services outside of the Service Area for reasons other than medical necessity.

Adverse Action. (i) The denial or limitation of authorization of a requested service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial of payment for a service; (iv) the failure to provide services in a timely manner; or (v) the failure to respond to a Grievance or an Appeal in a timely manner, ; or (vi) solely with respect to an Demonstration Plan that is the only Contractor serving for a rural areaarea resident, with only one Contractor, the denial of an Enrollee’s request to obtain services outside of the Service Area for reasons other than medical necessitynetwork.

Adverse Action. (i) The denial or limitation of authorization of a requested service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial of payment for a service; (iv) the failure to provide services in a timely manner; or (v) the failure to respond to an Appeal in a timely manner, or (vi) solely with respect to an Demonstration Plan that is the only Contractor serving a rural area, the denial of an Enrollee’s request to obtain services outside of the Service Area for reasons other than medical necessity.

Adverse Action. (i) The denial or limitation of limited authorization of a requested service authorization request, including the type or level of service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial of payment for a service; (iv) the failure to provide services in a timely manner; (iv) or the denial in whole or in part of a payment for a Covered Service for an Enrollee; (v) the failure by the STAR+PLUS MMP to respond to an Appeal in render a timely manner, or (vi) solely with respect to an Demonstration Plan that is decision within the only Contractor serving a rural area, the denial of an Enrollee’s request to obtain services outside of the Service Area for reasons other than medical necessity.required timeframes; or