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 ?
7 (c) For an external review of any issue in an adverse determination by a health plan company that requires a medical necessity determination, the external review must determine whether the adverse determination was consistent with the definition of medically necessary care in section62Q.
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).
After an initial hearing and an adverse determination, Tucker appealed the determination with the Tax Court, contending that the IRS Office of Appeals improperly rejected an OIC that he had proposed.
Such notification must disclose to the participant the specific reason for the adverse determination as well as the specific provisions of the plan upon which such determination was made.
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:
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.
In the event of a denial or adverse determination, SGC is expected to file a new rate case.
Tenders are invited for provide legal advice, assistance, and representation to eligible individuals ("eligible individuals") in matters involving the existence or scope of private or public insurance coverage for substance abuse treatment, including appeals of adverse determinations and litigation.
Under the current contract, MAXIMUS Federal also conducts reconsiderations of adverse determinations related to prior creditable prescription drug coverage and imposition of a late enrollment penalty under the Medicare Part D program.