Common use of Initial Adverse Determination Clause in Contracts

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone phone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one 1 working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone phone notice. Our notice will include: • · Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • · The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • · An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one (1) working day of a telephone phone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written prior authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one 1 working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one 1 working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written Prior Authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone phone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.. Benefits‌‌‌

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare health care service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare health care plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Health Care Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone phone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written prior authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.

Initial Adverse Determination. If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by telephone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare health care service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare health care plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Health Care Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written prior authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.