Urgent Care Claims. In the case of a Claim Involving Urgent Care, the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member shall be notified, in accordance with paragraph X. xxxxxx, of the Grievance Decision as soon as possible, taking into account the medical exigencies, but not later than 24 hours after receipt of the Member's request for review of an Adverse Decision. A written Notification must be provided to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within 24 hours of the orally communicated Grievance Decision.
Urgent Care Claims. Aetna will notify the covered person of an urgent care claim decision as soon as possible, but not later than 72 hours after the claim is made. With respect to mental health or substance abuse disorders, the decision will be made within 24 hours. If more information is needed to make an urgent care claim decision, Aetna will notify the claimant within 72 hours of receipt of the claim. The claimant has 48 hours after receiving such notice to provide Aetna with the additional information. Aetna will notify the claimant within 48 hours of the earlier to occur: • The receipt of the additional information; or • The end of the 48 hour period given the physician to provide Aetna with the information. Pre-Service Claims Aetna will notify the covered person of a pre-service claim decision as soon as possible, but not later than 15 calendar days after the claim is made. Aetna may determine that due to matters beyond its control an extension of this 15 calendar day claim decision period is required. Such an extension, of not longer than 15 additional calendar days, will be allowed if Aetna notifies the covered person within the first 15 calendar day period. If this extension is needed because Aetna needs more information to make a claim decision, the notice of the extension shall specifically describe the required information. The covered person will have 45 calendar days, from the date of the notice, to provide Aetna with the required information.
Urgent Care Claims. An Urgent Care claim is any pre-service claim where a delay in the review and adjudication of the claim could seriously jeopardize the Member’s life or health or ability to regain maximum function or subject the Member to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim.
Urgent Care Claims. Section 6.09 Application of Part II 6.3 Section 6.10 Definition of Urgent Care Claim 6.3
Urgent Care Claims. In the case of a claim involving urgent care, as defined by applicable regulations, the carrier shall notify the primary enrollee of the benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the primary enrollee’s request for review of an adverse benefit determination. Art. I, 6(b)(3) Pre-service Claims - In the case of a pre-service claim, as defined by applicable regulations, the carrier shall notify the primary enrollee of the benefit determination on review within a reasonable period of time, appropriate to the medical circumstances, but not later than 30 days after receipt by the carrier of the primary enrollee’s request for review of an adverse benefit determination. In the case of a carrier that provides for two appeals of an adverse determination, such notification shall be provided, with respect to any one of such two appeals, not later than 15 days after receipt by the carrier of the primary enrollee’s request for review of the adverse benefit determination. Post-service Claims - In the case of a post-service claim, as defined by applicable regulations, the carrier shall notify the primary enrollee of the benefit determination on review within a reasonable period of time, but not later than 60 days after receipt by the carrier of the primary enrollee’s request for review of an adverse benefit determination. In the case of a carrier that provides for two appeals of an adverse determination, such notification shall be provided, with respect to any one of such two appeals, not later than 30 days after receipt by the carrier of the primary enrollee’s request for review of the adverse benefit determination. The time periods specified for each category of claims above may be extended in accordance with applicable regulations. The written decision on the review will include the specific reasons for the decision and will set forth specific reference to Program provisions upon which the decision is based. If the review by the carrier results in an adverse determination, the primary enrollee may initiate an action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA). Art. I, 6(c)
Urgent Care Claims. In the case of a Claim Involving Urgent Care, the Organization shall notify the claimant of the benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the Organization, unless the claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such a failure, the Organization shall notify the claimant as soon as possible, but not later than 24 hours after receipt of the claim by the Organization, of the specific information necessary to complete the claim. The claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Notification of any Adverse Benefit Determination pursuant to this paragraph shall be made in accordance with the Notice requirements set forth in Section 11.07. The Organization shall notify the claimant of the benefit determination as soon as possible, but in no case later than 48 hours after the earlier of:
Urgent Care Claims. In the case of a Claim Involving Urgent Care, the Reviewing Fiduciary shall notify the claimant, in accordance with the Notice requirements set forth herein, of the benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant’s request for review of an Adverse Benefit Determination by the Reviewing Fiduciary.
Urgent Care Claims. A determination will be made within 72 hours from receipt of your appeal.
Urgent Care Claims i. If your Request is complete, MedTrak must notify you and your provider of the benefit determination within 72 hours.
Urgent Care Claims. In the case of a claim for medical care or treatment with respect to which the application of the time periods set forth in (b), (c) or (d) below could seriously jeopardize the life or health of the Participant or Dependent or his or her ability to regain maximum function, or would (in the opinion of a physician with knowledge of the Participant's or Dependent's medical condition) subject the Participant or Dependent to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim (“Urgent Care Claim”), the Board (or its designee) will notify the Claimant of the Fund’s decision as soon as possible but no later than 72 hours after receipt of the claim (or 24 hours after receipt of a claim to extend the course of treatment beyond the period of time or number of treatments approved by the Fund, if the claim is received at least 24 hours before the expiration of the approved period of time or number of treatments). Notwithstanding the foregoing sentence, if the Claimant does not provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan, the Board (or its designee) will notify the Claimant of the specific information necessary to complete the claim as soon as possible but no later than 24 hours after receipt of the claim. The Claimant will then have 48 hours (or such longer time as is reasonable in the circumstances) to provide the specified information, and the Board (or its designee) will notify the Claimant of the Fund’s decision as soon as possible, but no later than 48 hours after the Fund’s receipt of the information (or the end of the period afforded the Claimant to provide the specified additional information if the Claimant fails to do so).
