Common use of Other Adverse Benefit Determinations Requiring Notice of Adverse Benefit Determination Clause in Contracts

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 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 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;; or (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.