Common use of Adverse Benefit Determination Due to Failure to Resolve Appeals or Grievances Within Prescribed Timeframes Clause in Contracts

Adverse Benefit Determination Due to Failure to Resolve Appeals or Grievances Within Prescribed Timeframes. (A) Failure of the Contractor to act within the prescribed timeframes provided for resolving and giving resolution notice for Appeals or Grievances constitutes an Adverse Benefit Determination. 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. If the Enrollee is not the Aggrieved Person, the Contractor shall provide the Notice of Adverse Benefit Determination to the Enrollee as well as the Aggrieved Person.