Content Overview
- Adverse Determination
- Annual Limits
- Case Manager
- Certificate of Creditable Coverage
- Coordination Of Benefits
- Co-Insurance
- Co-Pay
- Covered Charges
- Department Of Insurance
- Deductible
- Eligibility
- Experimental Treatment
- Explanation Of Benefits
- Extensions
- Fee-For-Service (Indemnity)
- Formulary
- Lifetime Limits
- HMO
- Medical Necessity (Medically Necessary)
- Out Of Network
- Out-of-Pocket Maximum (also known as "Stop Loss" or "Cap")
- Palliative Care
- POS
- PPO
- Renewability
- Pre-Existing Health Condition
- Stop Clause (also known as "Stop Loss Clause")
- Underwriting (What It Is And How It Works)
- U.S. Department Of Labor
- Usual, Customary and Reasonable "(UCR")
- Utilization Management
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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