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Glossary of Health Insurance Terms To Know

Adverse Determination

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An Adverse Determination is a decision by an insurer not to pay for a particular drug or treatment. There can be a variety of reasons for the decision. 

Patients have the right to appeal an Adverse Determination by following the insurer's appeal process.  If that doesn't work, patients generally have a right to appeal to an independent reviewer who is not connected with the insurer.

Appealing an Adverse Determination inside the insurance company is known as appealing internally. Appealing outside the insurance company is known as appealing externally.


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