administrative denial definition
Definition of Terms. In compliance with State requirements, ValueOptions defines the following terms related to. Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial of services, or claims payment for services, based on reasons other. than a lack of medical necessity. Administrative Appeal: A request by an Enrollee, Enrollee-designated representative, or provider to. reconsider an administrative denial. Adverse Determination: A determination that the health care services requested or proposed to be. provided to an Enrollee are not medically necessary.