Final Adverse Benefit Determination definition

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

Final Adverse Benefit Determination means the upholding of an Adverse Benefit Determination at the conclusion of the internal appeals process or an Adverse Benefit Determination in which the internal appeals process has been deemed exhausted. External Review is only available for a Final Adverse Benefit Determination based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a Covered Service.

Final Adverse Benefit Determination means the upholding of an Adverse Benefit Determination at the conclusion of the internal appeals process or an Adverse Benefit Determination in which the internal appeals process has been deemed exhausted.

Examples of Final Adverse Benefit Determination in a sentence

• This request is an "Appeal." If the Claim is denied at the end of the Appeal process, as described below, the Plan's final decision is known as a "Final Adverse Benefit Determination." If the claimant receives notice of a Final Adverse Benefit Determination, or if the Plan does not follow the Appeal procedures properly, the claimant then has the right to request an independent external review.

• Before the Plan Administrator issues its Final Adverse Benefit Determination based on a new or additional rationale, the claimant must be provided, free of charge, with a copy of the rationale.

• This request is an "Appeal." If the Claim is denied at the end of the Appeal process, as described below, the Plan's final decision is known as a "Final Adverse Benefit Determination." Both the Claims and the Appeal procedures are intended to provide a full and fair review.

• You will have an opportunity to respond before our timeframe for issuing a notice of Final Adverse Benefit Determination expires.You will receive continued coverage pending the outcome of the appeals process.

• You will have an opportunity to respond before our time frame for issuing a notice of Final Adverse Benefit Determination expires.

More Definitions of Final Adverse Benefit Determination

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

Final Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the completion of the Plan’s appeals procedure or an Adverse Benefit Determination for which the Plan’s appeals procedures were not properly followed.

Final Adverse Benefit Determination means an ABD upheld at the completion of a health plan issuer’s internal appeals process.

Final Adverse Benefit Determination means an Adverse Benefit Determination issued in connection with the last stage of Appeal as set forth in the Appeals Section.

Final Adverse Benefit Determination means an Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Molina, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.

Final Adverse Benefit Determination means an adverse benefit determination that has been upheld by a carrier at the completion of the carrier's internal review process.

Final Adverse Benefit Determination means any claims denial, or partial de- nial, upheld by the Trustees, or by their claims review committee, upon ap- peal.