Common use of Adverse Benefit Determination Clause in Contracts

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

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.