Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination. 7.2.1 Adverse Benefit Determination to Reduce, Suspend or Terminate Previously Authorized Covered Services
(A) If the Contractor seeks to reduce, suspend, or terminate previously authorized Covered Services, this constitutes an Adverse Benefit Determination.
(B) The Contractor shall notify the requesting Provider and mail a Notice of Adverse Benefit Determination to the Enrollee as expeditiously as the Enrollee’s health condition requires and within the following timeframes:
Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination. 7.2.1 Adverse Benefit Determination to Reduce, Suspend or Terminate Previously Authorized Covered Services
Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination. Adverse Benefit Determination to Deny Payment in Whole or Part for a Service
Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination. 7.2.1 Adverse Benefit Determination to Deny in Whole or in Part, Payment for a Service
(A) The Contractor shall provide a written Notice of Adverse Benefit Determination to the requesting Provider of decisions to deny payment in whole or in part but not if the denial, in whole or in part, of a payment for a service is solely because the Claim does not meet the definition of a Clean Claim.
(B) The Contractor shall also mail the Enrollee a written Notice of Adverse Benefit Determination at the time of the Adverse Benefit Determination affecting a claim if the denial reason is that:
(1) the service was not authorized by the Contractor, and the Enrollee could be liable for payment if the Enrollee gave advance written consent that he or she would pay for the specific service; or
(2) the Enrollee requested continued services during an Appeal or State Fair Hearing and the Appeal or State Fair Hearing decision was adverse to the Enrollee.
(C) A Notice of Adverse Benefit Determination to the Enrollee is not necessary under the following circumstances:
(1) the Provider billed the Contractor in error for a non-authorized service;
(2) the Claim included a technical error (incorrect data including procedure code, diagnosis code, Enrollee name or Medicaid identification number, date of service, etc.); or
(3) the Enrollee became eligible after the first of the month, but received a service during that month before becoming Medicaid eligible.
Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination. 7.2.1 Adverse Benefit Determination to Reduce, Suspend or Terminate Previously Authorized Covered Services
(A) If the Contractor seeks to reduce, suspend, or terminate previously authorized Covered Services, this constitutes an Adverse Benefit Determination.
(B) The Contractor shall notify the requesting Provider and mail a Notice of Adverse Benefit Determination to the Enrollee as expeditiously as the Enrollee’s health condition requires and within the following timeframes:
(1) at least 10 calendar days prior to the date of the Adverse Benefit Determination;
(2) five calendar days before the date of the Adverse Benefit Determination if the Contractor has facts indicating that the Adverse Benefit Determination should be taken because of probable Fraud by the Enrollee, and the facts have been verified, if possible, through secondary sources;
(3) by the date of the Adverse Benefit Determination if:
(i) the Contractor has factual information confirming the death of the Enrollee; or
(ii) the Contractor receives a clear, written statement from the Enrollee that:
(a) the Enrollee no longer wishes the services; or
(b) the Enrollee gives information that requires termination or reduction of services and indicates that the Enrollee understands that this must be the result of supplying that information;
(iii) the Enrollee has been admitted to an institution where the Enrollee is ineligible for further services;
(iv) the Enrollee’s whereabouts are unknown and the post office returns mail directed to the Enrollee indicating no forwarding address. In this case any discontinued services shall be reinstated if the Enrollee's whereabouts become known during the time the Enrollee is eligible for services;
(v) the Enrollee has been accepted for Medicaid services by another local jurisdiction; or
(vi) the Enrollee’s physician prescribes the change in the level of medical care.
7.2.2 Adverse Benefit Determination to Deny in Whole or in Part, Payment for a Service
(A) The Contractor shall provide a written Notice of Adverse Benefit Determination to the requesting Provider of decisions to deny payment in whole or in part but not if the denial, in whole or in part, of a payment for a service is solely because the Claim does not meet the definition of a Clean Claim.
(B) The Contractor shall also mail the Enrollee a written Notice of Adverse Benefit Determination at the time of the Adverse Benefit Determination affecting a Claim if the denial reason is that:
(1) the service was no...
