Final Adverse Benefit Determination Sample Clauses

Final Adverse Benefit Determination. An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.
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Final Adverse Benefit Determination. An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination. Post-Service Claim An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or Your unborn child’s; or • In the opinion of the treating physician, would subject You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or Your Authorized Representative, or a treating Provider or facility may submit an appeal. If You need assistance in preparing the appeal, or in submitting an initial appeal (Level I) verbally, You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Alliant Health Plans Administrative PO BOX 1247 Claims Appeals: Dalton, GA 30722 Med Pharm Magellan Rx Management Appeals: Appeals Department PO BOX 1459 Maryland Heights, MO 63043 Pharmacy Magellan Rx Management Appeals: Appeals Department PO BOX 1599 Maryland Heights, MO 63043 If You are Hearing impaired, You may also contact Alliant via the National Relay Service at 711. You (or Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact You (or Your Authorized Representative) in writing or by telephone to inform You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care prof...
Final Adverse Benefit Determination. An adverse benefit determination that has been upheld by Aetna at the exhaustion of the appeals process.
Final Adverse Benefit Determination. If a Claim is denied at the end of the internal Appeal process, the Plan’s final decision is known as a “Final Adverse Benefit Determination.”
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