Adverse Benefit Determinations. 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, • Denial, reduction, termination, or failure to make a payment based on the imposition of a preexisting condition exclusion, a source of injury exclusion, or other limitation on covered benefits, 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 at (000) 000-0000 or 0-000-000-0000.
Adverse Benefit Determinations. Insurer shall provide timely and adequate written notice of an Adverse Benefit Determination. The benefit determination and any notice of Adverse Benefit Determination must be provided within the following timeframes in accordance with 42 CFR 457.1260 and to the extent it incorporates 42 CFR part 438 subpart F:
a. For termination, suspension, or reduction of previously approved services, the notice must be provided at least ten (10) Calendar Days before the date of action except when:
i. Insurer has information confirming the death of the Enrollee;
ii. Insurer receives a clear signed written statement from the Enrollee stating that the Enrollee no longer wishes to receive services, or the Enrollee gives information that requires termination or reduction of services and the Enrollee indicates understanding that termination or reduction of services must be the outcome of providing such information;
iii. The Enrollee has been admitted to an institution which causes ineligibility under the plan for further services;
iv. The Enrollee’s whereabouts are unknown and the United States Postal Service returns Insurer’s mail to the Enrollee with no forwarding address;
v. Insurer establishes that the Enrollee is enrolled in Florida Healthy Kids with another insurer;
vi. A change in the level of medical care is prescribed by the Enrollee’s physician;
vii. The notice involves an Adverse Benefit Determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act;
viii. In accordance with 42 CFR 431.213(h); and
ix. Insurer has facts, verified through secondary sources when possible, indicating that action should be taken because of probable Fraud by the Enrollee. In such instances the notice must be provided at least five (5) Calendar Days before the date of action.
b. For denial of payment, the notice must be provided at the time of any action affecting the claim;
c. For standard service authorization decisions that deny or limit services, within fourteen
Adverse Benefit Determinations. 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 at (000) 000-0000 or 0-000-000-0000.
