Common use of Decisions to Reduce, Suspend, or Terminate Previously Authorized Covered Services Clause in Contracts

Decisions to Reduce, Suspend, or Terminate Previously Authorized Covered Services. (A) If the Contractor seeks to reduce, suspend, or terminate previously authorized Covered Services, this constitutes an Adverse Benefit Determination. (B) The Contractor shall notify the requesting Provider and mail a Notice of Adverse Benefit Determination to the Enrollee as expeditiously as the Enrollee’s health condition requires and within the following timeframes: (1) at least 10 calendar days prior to the date of the Adverse Benefit Determination; or (2) five calendar days before the date of the Adverse Benefit Determination if the Contractor has facts indicating that the Adverse Benefit Determination should be taken because of probable Fraud by the Enrollee, and the facts have been verified, if possible, through secondary sources; or (3) by the date of the Adverse Benefit Determination if: (i) the Contractor has factual information confirming the death of the Enrollee; (ii) the Contractor receives a clear, written statement from the Enrollee that: (a) the Enrollee no longer wants the services; or (b) the Enrollee gives information that requires termination or reduction of services and indicates that the Enrollee understands that this shall be the result of supplying that information; (iii) the Enrollee has been admitted to an institution where he is ineligible for further services; (iv) the Enrollee’s whereabouts are unknown and the post office returns mail directed to him indicating no forwarding address. In this case any discontinued services shall be reinstated if his whereabouts become known during the time he is eligible for services; (v) the Enrollee has been accepted for Medicaid services by another local jurisdiction; or (vi) the Enrollee’s physician prescribes the change in the level of medical care.

Decisions to Reduce, Suspend, or Terminate Previously Authorized Covered Services. (A) If the Contractor seeks to reduce, suspend, or terminate previously authorized Covered Services, this constitutes an Adverse Benefit Determination. (B) The Contractor shall notify the requesting Provider and mail a Notice of Adverse Benefit Determination to the Enrollee as expeditiously as the Enrollee’s health condition requires and within the following timeframes: (1) at least 10 calendar days prior to the date of the Adverse Benefit Determination; or; (2) five calendar days before the date of the Adverse Benefit Determination if the Contractor has facts indicating that the Adverse Benefit Determination should be taken because of probable Fraud by the Enrollee, and the facts have been verified, if possible, through secondary sources; or (3) by the date of the Adverse Benefit Determination if: (i) the Contractor has factual information confirming the death of the Enrollee; (ii) the Contractor receives a clear, written statement from the Enrollee that: (a) the Enrollee no longer wants the services; or (b) the Enrollee gives information that requires termination or reduction of services and indicates that the Enrollee understands that this shall be the result of supplying that information; (iii) the Enrollee has been admitted to an institution where he is ineligible for further services; (iv) the Enrollee’s whereabouts are unknown and the post office returns mail directed to him indicating no forwarding address. In this case any discontinued services shall be reinstated if his whereabouts become known during the time he is eligible for services; (v) the Enrollee has been accepted for Medicaid services by another local jurisdiction; or (vi) the Enrollee’s physician prescribes the change in the level of medical care.