Adverse Determination

Adverse Determination

Malpractice Complaint
Managed care A determination by an HMO’s utilisation reviewers not to certify, either before, during or after services are received, an admission, service, procedure or extension of stay, or a denial of a claim, because, based on the information provided, the request does not meet a particular HMO’s requirements for medical necessity under its managed care contract.
References in periodicals archive ?
Connecticut requires that health plans provide a member subject to an adverse determination with "a website link that pinpoints definitively the specific clinical criteria used to establish and to absolutely quantify all health benefit determinations".
If a provider receives an adverse determination from an ALL the provider then has 60 days to file an appeal to the Medicare Appeals Council (MAC).
REFLECTIONS: The Second Circuit stated that it is not entirely clear that the Tax Court would even have jurisdiction over an electing spouse's petition for review of an adverse determination under Sec.
The preliminary adverse determination offers the issuer three opportunities: a conference with the agent's TEB Group manager; taxpayer--initiated technical advice; or assistance from the Office of the Taxpayer Advocate.
9935, "Administrative Appeal of Proposed Adverse Determination of Tax-Exempt Status of Bond Issue," Internal Revenue Bulletin 1999-41, October 12, 1999).
Specifically, in order to avoid an adverse determination, the compensation arrangement in a service or management contract must:
The Court also determined that the purported annulment by the Treasury Department of the Closing Agreement is not a final decision, but rather is only a preliminary adverse determination to commence a formal adjudicative process, thereby providing Doral its opportunity to challenge the decision through an administrative proceeding before the Treasury Department, and affording Doral the benefits of due process of law.
The fines announced today relate to Adverse Determination Letters sent by the FDA to the Red Cross in October.
These risks and uncertainties include, but are not limited to, the outcome of the Nasdaq hearing; the impact of a potential adverse determination from Nasdaq; the possibility that Radio One may continue to be unable able to file the requisite periodic reports on a timely basis; and the timing, results and final conclusions of the audit committee's review of Radio One's stock option grant practices; and completion of its restated and current financial statements.
Pending an adverse determination by the Panel, the Company's securities will continue to be traded on The Nasdaq Stock Market.
In the event of an adverse determination regarding the Company's inclusion into the Nasdaq SmallCap Market, the Company intends to request for an appeal which will stay the delisting process.