Common use of Content of Notice Clause in Contracts

Content of Notice. a. The notice shall explain the following: i. The adverse benefit determination the Contractor has made or intends to make. ii. The reasons for the adverse benefit determination, including the right of the beneficiary to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the beneficiary’s adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits.

Content of Notice. a. The notice shall explain the following: i. The adverse benefit determination the Contractor has made or intends to make. ii. The reasons for the adverse benefit determination, including the right of the beneficiary to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the beneficiary’s adverse benefit determination. Such information includes medical necessity criteriaDMC-ODS criteria for services, and any processes, strategies, or evidentiary standards used in setting coverage limits.