Adverse benefit definition

Adverse benefit determinations” are decisions made by HMO that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service or termination of a Member's coverage back to the original effective date (rescission). Such adverse benefit determination may be based on: • Your eligibility for coverage. • Coverage determinations, including plan limitations or exclusions; except when the Member presents evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply to the denied benefit. • The results of any Utilization Review activities. • A decision that the service or supply is an Experimental or Investigational Procedure. • A decision that the service or supply is not Medically Necessary. A “final adverse benefit determination” is an adverse benefit determination that has been upheld by HMO at the exhaustion of the Appeals process. HMO Timeframe for Notification of a Benefit Determination Type of Claim Response Time from Receipt of Claim Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. As soon as possible, but not later than 72 hours Pre-Service Claim. A claim for a benefit that requires pre-authorization of the benefit in advance of obtaining medical care. Within 15 calendar days Concurrent Care Claim Extension. A request to extend a course of treatment previously pre-authorized by HMO. If an Urgent Care claim as soon as possible, but not later than 24 hours. Otherwise, within 15 calendar days Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. With enough advance notice to allow the Member to Appeal Post-Service Claim. A claim for a benefit that is not a pre-service claim. Within 30 calendar days As to a Concurrent Care Claim Reduction or Termination, if the Member files an Appeal, Covered Benefits under the Certificate will continue for the previously approved course of treatment until a final Appeal decision is rendered. During this continuation period, the Member is responsible for any Copayments and Deductibles that apply to the services; supplies; and treatment; that are rendered in connection with the claim that i...
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Examples of Adverse benefit in a sentence

  • Adverse benefit determinations that are based on contractual or legal interpretations without any use of medical judgment; and2.

  • Adverse benefit determinations that are based on a failure to meet requirements for eligibility under a group health plan.Standard External Review ProceduresThere are two types of external review: a standard external review and an expedited external review.

  • Adverse benefit determination (action) means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a plan.

  • Adverse benefit determinations are decisions Delta Dental makes that result in denial, reduction or termination of a benefit or amount paid.

  • Adverse benefit determinations that are based on a failure to meet requirements for eligibility under a group health plan.

  • Adverse benefit determination (action) means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Enrollee’s eligibility to participate in a plan.KFHPWA will comply with any new requirements as necessary under federal laws and regulations.

  • Notice to Insured of Adverse Benefit Determination Adverse benefit determination means a denial, reduction, termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination or failure to provide or make payment that is based on a determination of a participant’s eligibility to participate in the plan.

  • Adverse benefit determination: means a decision by the Plan or a representative of the Plan to deny, reduce, terminate or modify the availability of any dental care services because you are not eligible for coverage, including a decision that your condition failed to meet the requirements for coverage based on necessity, appropriateness of care, level of care, or effectiveness.

  • Adverse benefit determinations can result from one or more of the following: • The individual is not eligible to participate in the dental plan; or • Delta Dental determines that a benefit or service is not a Covered Benefit because: • it is not included in the list of Covered Benefits, • it is specifically excluded, • a benefit limitation under the dental plan has been reached, or • it is not necessary or customary for the diagnosis or treatment of your condition [Dental Necessity].

  • Within four months after the date of receipt of a notice of an Adverse Benefit Determination or Final Internal Adverse benefit from the Claim Administrator, You or Your authorized representative must file Your request for standard external review.2. Preliminary review.

Related to Adverse benefit

  • Adverse Benefit Determination means any of the following:

  • Final Adverse Benefit Determination means an adverse benefit determination that is upheld at the completion of a health plan issuer’s internal appeals process.

  • Defined Contribution Dollar Limitation means, for any Limitation Year, $46,000, as adjusted for increases in the cost-of-living under Code section 415(d). If a short Limitation Year is created because of a Plan amendment changing the Limitation Year to a different 12-consecutive month period, the Defined Contribution Dollar Limitation for the short Limitation Year will not exceed the amount determined in the preceding sentence multiplied by a fraction, the numerator of which is the number of months in the short Limitation Year and the denominator of which is 12.

  • Pension Benefit means a pension, annuity, gratuity or similar allowance which is payable—

  • Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX’s internal review/appeal process.

  • material benefit means a benefit which may not be financial but has a monetary value;

  • Supplemental Retirement Income Benefit means an annual amount (before taking into account federal and state income taxes), payable in monthly installments throughout the Payout Period. Such benefit is projected pursuant to the Agreement for the purpose of determining the Contributions to be made to the Retirement Income Trust Fund (or Phantom Contributions to be recorded in the Accrued Benefit Account). The annual Contributions and Phantom Contributions have been actuarially determined, using the assumptions set forth in Exhibit A, in order to fund for the projected Supplemental Retirement Income Benefit. The Supplemental Retirement Income Benefit for which Contributions (or Phantom Contributions) are being made (or recorded) is set forth in Exhibit A.

  • Public benefit means making capital available, or facilitating the availability of capital, to businesses in this state that have 750 or fewer employees, the intent of which is to create or retain employment opportunities for residents of this state, stabilize or increase the tax base of this state, or support the redevelopment of facilities for use by small businesses.

  • Net Benefit means the present value of the Covered Payments net of all federal, state, local, foreign income, employment and excise taxes.

  • Canadian Defined Benefit Pension Plan means a Canadian Pension Plan which contains a “defined benefit provision,” as defined in subsection 147.1(1) of the Income Tax Act (Canada).

  • Lifetime Benefit Limit means the maximum amount of benefits paid by the Company to the Policy Holder cumulatively since the inception of these Terms and Benefits, irrespective whether any limits of any benefit items stated in the Benefit Schedule have been reached or whether the Annual Benefit Limit in a Policy Year has been reached.

  • Canadian Benefit Plan means any plan, fund, program or policy, whether oral or written, formal or informal, funded or unfunded, insured or uninsured, providing employee benefits, including medical, hospital care, dental, sickness, accident, disability, life insurance, pension, retirement or savings benefits, under which any Loan Party has any liability with respect to any of its employees or former employees employed in Canada, and includes any Canadian Pension Plan.

  • Supplemental Retirement Benefit means the benefit determined under Article V of this Plan.

  • Supplemental Benefit means the monthly benefit payable to the Executive under this Agreement.

  • Parent Benefit Plan means any Employee Benefit Plan maintained by, sponsored by or contributed to by, or obligated to be contributed to by any Parent Group Entity.

  • BENEFIT LIMIT means the total benefit allowed under this plan for a covered healthcare service. The benefit limit may apply to the amount we pay, the duration, or the number of visits for a covered healthcare service.

  • Disability Benefit means the benefit set forth in Article 8.

  • Termination Benefit means the benefit set forth in Article 7.

  • Continuing care retirement community means a residential

  • Non-U.S. Benefit Plan has the meaning set forth in Section 3.20(a).

  • Annual Benefit Limit means the maximum amount of benefits paid by the Company to the Policy Holder in a Policy Year irrespective of whether any limits of any benefit items stated in the Benefit Schedule have been reached. The Annual Benefit Limit is counted afresh in a new Policy Year.

  • Company Pension Plan means each: (a) Company Employee Plan that is an “employee pension benefit plan,” within the meaning of Section 3(2) of ERISA; or (b) other occupational pension plan, including any final salary or money purchase plan.

  • Retirement Benefit means the benefit set forth in Article 5.

  • Disability Support Pension means the Commonwealth pension scheme to provide income security for persons with a disability as provided under the Social Security Act 1991, as amended from time to time, or any successor to that scheme.

  • Plan Benefit means the benefit payable to a Participant as calculated in Article V.

  • Pre-Retirement Survivor Benefit means the benefit set forth in Article 6.