Common use of Notification of an Adverse Benefit Determination Clause in Contracts

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.

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.

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 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.

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 experimentalExperimental, investigational Investigational or unproven 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.

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 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.

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 experimentalExperimental, investigational Investigational or unproven 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.

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.. Evidence of Coverage

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.. Evidence of Coverage