Adverse Benefit Determination. The denial or limited authorization of a requested service, including determinations on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; the reduction, suspension, or termination of a previously authorized services; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by the Division; the failure of the Contractor to act within the timeframes provided in 42 C.F.R. § 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals; for residents in a rural area with only one MCO, the denial of an enrollee’s request to exercise his or her right, under 42 C.F.R. § 438.52(b)(2)(ii); the denial of an enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities; and determinations by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determinations made by a State with regard to the preadmission screening and annual resident review requirements of Section 1919(e)(7) of the Act, if applicable.
Adverse Benefit Determination. An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
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; (v) the failure of the 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 Contractor, 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 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. Except for non-payment, we will not contest this policy after it has been in force for a period of two years from the later of the plan effective date or latest reinstatement date.
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 Benefit Determination. We will reimburse the lesser of the provider’s charges or the maximum benefit amount shown in the Summary of Medical Benefits.
Adverse Benefit Determination 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 benefit; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure of Insurer to provide services in a timely manner, as defined by FHKC; the failure of Insurer to act within the timeframes required by law for standard resolution of Grievances and Appeals; and the denial of an Enrollee’s request to dispute a financial liability, including cost sharing, premiums, and other Enrollee financial liabilities. After-hours Services: outpatient Covered Services that are not Emergency Services and are provided at a time other than Monday through Friday, 8:00 a.m. to 5:00 p.m. Agency for Health Care Administration: the lead agency for Title XXI of the Act for purposes of receipt of federal funds, reporting, and for ensuring compliance with federal and State regulations and rules. Appeal: a review by Insurer of an Adverse Benefit Determination.
Adverse Benefit Determination. Any one of the following actions or inactions by the Contractor:
1.7.1 The denial or limited authorization of a requested service, including determinations based on the type of service, requirements for medical necessity, appropriateness, setting or effectiveness of a Covered Service.
1.7.2 The reduction, suspension, or termination of a previously authorized service;
1.7.3 The denial, in whole or in part, of payment for a service, where coverage of the requested service is at issue; provided that procedural denials for requested services do not constitute Adverse Benefit Determinations, including but not limited to denials based on the following: • Failure to follow prior authorization procedures; • Failure to follow referral rules; • Failure to file a timely claim;
1.7.4 The failure to provide Covered Services in a timely manner in accordance with the accessibility standards in Section 2.9;
1.7.5 The failure to act within the timeframes provided in Section 2.9.4.7 for making an authorization decision;
1.7.6 The denial of an Enrollee‘s request to obtain services outside of the network;
1.7.7 The denial of an Enrollee‘s request to dispute a financial liability; and
1.7.8 The failure to act within the timeframes in Section 2.12.2 for reviewing an internal Appeal and issuing a decision.
Adverse Benefit Determination. (i) The denial or limited authorization of an Enrollee or Provider-requested service, including the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service unless the payment is denied solely because the Claim does not meet the definition of a Clean Claim; (iv) the failure to provide services in a timely manner, as defined by the State; (v)the failure of the STAR+PLUS MMP to act within the required timeframes in the Contract; (vi) for a resident of a rural area with only one STAR+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, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities. 239
