Adverse Benefit Determination
Also called: adverse determination
An adverse benefit determination is the official term for a decision by a health plan that goes against you: denying a service, paying less than expected, ending a treatment the plan was covering, or refusing to pay a claim. Federal rules require the plan to explain the reason in writing and to tell you how to appeal. Recognizing a letter as an adverse benefit determination matters because it starts the clock on your appeal deadlines.