Common use of Adverse Benefit Determination Clause in Contracts

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. Any one of the following actions or inactions by the Contractor: 1.7.1 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 1.7.2. The reduction, suspension, or termination of a previously authorized service; 1.7.3 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 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 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 1.7.6. The denial of an Enrollee‘s Enrollee’s request to obtain services outside of the network; 1.7.7 1.7.7. The denial of an Enrollee‘s Enrollee’s request to dispute a financial liability; and 1.7.8 1.7.8. The failure to act within the timeframes in Section 2.12.2 for reviewing an internal Appeal and issuing a decision.