Adverse Determination (Health Care) Law & Legal Definition


Adverse determination in the context of health care refers to the determination made by a health care plan or by a utilization review program, that a health care service is not medically necessary. It also refers to the decision taken by the Office of Personnel Management barring health care service providers or suppliers from participating in the health care program. Any health care services provider or supplier subject to an adverse determination by the Office under 5 USCS § 8902a (h)(1) section shall be entitled to reasonable notice, an opportunity to request a hearing of record, and to judicial review after the Office renders a final decision.