Adverse Benefit Determination definition

Adverse Benefit Determination means any of the following:

Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

Adverse Benefit Determination means a decision by a health plan issuer:

Examples of Adverse Benefit Determination in a sentence

• The Contractor’s failure to provide resolution of the Appeal within the required timeframe is an Adverse Benefit Determination and the Aggrieved Person is allowed to file a request for a State Fair Hearing as the Aggrieved Person has already exhausted the Contractor’s internal Appeals process.

• The Aggrieved Person may request a standard Appeal, either orally or in writing, within 60 calendar days from the date on the Contractor’s written Notice of Adverse Benefit Determination.

• The Contractor is required to send out a Notice of Adverse Benefit Determination to the Enrollee and the Provider on the date that the timeframe expires.

• The Contractor shall pay for Covered Services related to an Adverse Benefit Determination deemed eligible for payment pursuant to the terms of a court or administrative order.

• The Contractor shall provide a Notice of Adverse Benefit Determination to the Enrollee at the time that either the Contractor determines, or the Enrollee or the Network Provider informs the Contractor, that the applicable performance standard found in Article 10.4 of this attachment for offering the first service to the Enrollee cannot be met, and the Enrollee informs the Contractor or the Network Provider that they are not satisfied with this.

More Definitions of Adverse Benefit Determination

Adverse Benefit Determination means a denial, reduction, or

Adverse Benefit Determination means a denial, reduction or the termination of, or a failure to provide or make payment (in whole or in part) with respect to a Claim 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 or Beneficiary’s eligibility to participate in the Plan.

Adverse Benefit Determination 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 Participant’s or beneficiary’s eligibility to participate in the Plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate, or a rescission of coverage if the Plan Administrator determines that the Employee or a Dependent engaged in fraud or intentional misrepresentation in order to obtain coverage and/or benefits under the Plan. In such case, the Participant will receive written notice at least thirty (30) days before the coverage is rescinded.

Adverse Benefit Determination 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 claimant’s eligibility to participate in a plan and with respect to a claim for benefits due to Executive being Permanently Disabled, shall also mean any rescission of disability coverage with respect to a Participant or Beneficiary (whether or not there is an adverse effect on any particular benefit at that time), where rescission means a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

Adverse Benefit Determination. Means denial or partial denial of a Benefit, in whole or in part, based on:

Adverse Benefit Determination means an insurer’s denial, reduction or termination of a

Adverse Benefit Determination 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, and including, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental/Investigational or not Medically Necessary or appropriate. An Adverse Benefit Determination also includes any Rescission of coverage (whether or not, in connection with the Rescission, there is an adverse effect on any particular benefit at that time).