Notification of an Adverse Benefit Determination Sample Clauses

Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you will be informed in writing of the following:  The specific reason or reasons for upholding the Adverse Benefit Determination;  Reference to the specific Plan provisions on which the determination is based;  A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary;  A description of the review procedures and the time limits applicable to such procedures;  For Member’s whose coverage is subject to ERISA, a statement of the Member’s right to bring a civil action under ERISA Section 502(a) following an appeal of an Adverse Benefit Determination, if applicable;  A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Member’s request; and  If the Adverse Benefit Determination is based on Medical Necessity or experimental, investigational or unproven treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge.
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Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you will be informed in writing of the following:  The specific reason or reasons for upholding the Adverse Benefit Determination;  Reference to the specific Plan provisions on which the determination is based;  A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary;  A description of the review procedures and the time limits applicable to such procedures;  For Insured’s whose coverage is subject to ERISA, a statement of the Insured’s right to bring a civil action under ERISA Section 502(a) following an appeal of an Adverse Benefit Determination, if applicable;  A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and  If the Adverse Benefit Determination is based on Medical Necessity or experimental, investigational or unproventreatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge.
Sample 1Sample 2See All (10)
Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you will be informed in writing of the following:  The specific reason or reasons for upholding the Adverse Benefit Determination;  Reference to the specific Plan provisions on which the determination is based;  A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary;  A description of the review procedures and the time limits applicable to such procedures;
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Notification of an Adverse Benefit Determination. Any request by a Member to extend the course of treatment beyond the period of time or number of treatments for an Urgent Care Claim shall be decided as soon as possible. HPN shall notify the Member within twenty-four (24) hours after receipt of the Claim for Benefits by the Plan, provided that the request is received at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments. If the request is not made at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments, the request will be treated as an Urgent Care Claim. If you receive an Adverse Benefit Determination, you will be informed in writing of the following: • The specific reason or reasons for upholding the Adverse Benefit Determination; • Reference to the specific Plan provisions on which the determination is based; • A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; • A description of the review procedures and the time limits applicable to such procedures; • For Member’s whose coverage is subject to ERISA, a statement of the Member’s right to bring a civil action under ERISA Section 502(a) following an appeal of an Adverse Benefit Determination, if applicable; • A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Member’s request; and • If the Adverse Benefit Determination is based on Medical Necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge.
Sample 1
Notification of an Adverse Benefit Determination. SHL shall notify the Insured within twenty-four (24) hours after receipt of the Claim for Benefits by the Plan, provided that the request is received at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments. If the request is not made at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments, the request will be treated as an Urgent Care Claim. If an Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization provided the Insured’s request for Prior Authorization is received by an employee or department of the Plan customarily responsible for handling benefit matters and the original request specifically named the Insured, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.
Sample 1
Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you will be informed in writing of the following: • The specific reason or reasons for upholding the Adverse Benefit Determination; • Reference to the specific Plan provisions on which the determination is based; • A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; • A description of the review procedures and the time limits applicable to such procedures; • A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and • If the Adverse Benefit Determination is based on Medical Necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge.
Sample 1
Notification of an Adverse Benefit Determination. The Administration Office shall provide a participant with a notice, either in writing or electronically containing the following information:
Sample 1
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Related to Notification of an Adverse Benefit Determination

  • Adverse Benefit Determination 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 (000) 000-0000 or 0-000-000-0000.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to an ICT technical, financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the President of the British Computer Society (or any other association that has replaced the British Computer Society). The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure by either Party to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his/her appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

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