Common use of Denials Clause in Contracts

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not medically necessary, a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing a medical appeal.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: •  a full or partial denial of a benefit; •  a reduction of a benefit; •  a termination of a benefit; •  a failure to provide or make a full or partial payment for a benefit; and •  a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not medically necessary, a determination letter will be provided with the following information: •  reason for the denial; •  clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and •  instructions for filing a medical appeal.