Adverse determination definition

Adverse determination shall have the meaning set forth in Section 19.7.
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Adverse determination means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, based on a determination of a member’s eligibility to participate in the 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 or investigational or not medically necessary or appropriate. An Adverse Determination does not mean a determination that the healthcare services are not covered services. The Plan Manager is responsible for the Internal Appeal Process for Adverse Determinations in accordance with KRS 304.17A-600 through 633.
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Adverse determination means a determination by a health maintenance organization or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health maintenance organization’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service is therefore denied, reduced or terminated.
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Examples of Adverse determination in a sentence

  • You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insurance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination.

  • For appeals relating to a determination based on treatment being experimental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit.

  • You or your authorized representative may make a request for a standard external review or expedited external review of an Adverse Determination or Final Adverse Determination by an independent review organization (IRO).


More Definitions of Adverse determination

Adverse determination means a determination by an HMO or Utilization Review agent that the Health Care Services furnished, or proposed to be furnished to a patient, are not Medically Necessary or not appropriate.
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Adverse determination means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
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Adverse determination means a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a covered person are:
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Adverse determination means a determination by a health
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Adverse determination means a determination made that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.
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Adverse determination means a de- cision by the proper Council official to deny, in whole or in part, a request from an individual for a correction or amendment of a record concerning the individual and maintained by the Council; and
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Adverse determination means a utilization review decision by a review agent not to
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