Compliance

Adverse determination

A decision by an insurer or review agent to deny, reduce, or terminate coverage for a healthcare service.

Definitions (2)

An adverse determination refers to a decision made by a private review agent or utilization review entity to deny, reduce, or terminate an insured's coverage for a healthcare service, based on a review of medical necessity or appropriateness.

AN ACT To amend Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, so as to provide that certain decisions with regard to the provision of insurance coverage for healthcare services shall not be based solely on artificial intelligence systems, artificial intelligence, or other software tools; to provide for definitions; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes.Definition 1 of 2

Refers to a denial, reduction, or termination of a requested healthcare service or payment, which, under the Act, must be made by qualified physicians or clinical peers.

Adopt the Ensuring Transparency in Prior Authorization Act and provide for insurance and medicaid coverage of biomarker testingDefinition 2 of 2
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