I nitial Claim Clause Samples
The Initial Claim clause defines the process by which a party formally notifies the other party of a claim or dispute under the contract. Typically, this clause outlines the required content of the notice, the timeframe within which it must be submitted, and the method of delivery, such as written notice to a specified address. Its core function is to ensure that all parties are promptly and clearly informed of potential issues, enabling timely resolution and preserving the rights of both sides.
I nitial Claim. Generally, the determination of whether a Claim is an Urgent Care Claim will be made by an individual acting on behalf of ▇▇▇▇▇, applying the judgment of a prudent layperson possessing an average knowledge of health and medicine. However, if a Physician with knowledge of the Member’s Condition determines that the Claim is an Urgent Care Claim, it will be deemed urgent. Urgent Care Claims may be made orally or in writing. AvMed will notify the Claimant of the benefit determination as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the Urgent Care Claim.
1) If the Claimant fails to provide sufficient information to determine whether or to what extent benefits are covered or payable under this Contract, AvMed will notify the Claimant, no later than 24 hours after receipt of the Claim, of the specific information necessary to complete the Claim. The Claimant will be afforded no less than 48 hours, to provide the specified information.
2) AvMed will notify the Claimant of the benefit determination no later than 48 hours after the earlier of: ▇▇▇▇▇’s receipt of the specified information, or the end of the period afforded the Claimant to provide the specified information. If the Claimant fails to supply the specified information within the 48-hour period, the Claim will be denied.
3) AvMed may notify the Claimant of the benefit determination orally or in writing. If the notification is provided orally, a written or electronic notification will also be provided to the Claimant no later than three days after the oral notification.
I nitial Claim. Post-Service Claims must be submitted to AvMed within 90 days from the date of service or within one year unless the Member was legally incapacitated; otherwise the Claim will be considered to have been waived.
1) Post-Service Claims must include all of the information listed below. If a Claim is for services received to treat an Emergency Medical Condition or an Urgent Medical Condition while outside the continental United States, Alaska or Hawaii, the information must be translated into English.
a) The name of the individual who received the services;
b) The Member’s name and Member ID number as they appear on the Member Identification Card;
c) The place of service and the date of service;
d) A description of the services including any applicable procedure codes;
e) The diagnosis including any applicable diagnosis codes;
f) The provider’s name and address; and
g) The amount actually charged by the provider and a copy of the paid receipts;
2) AvMed will notify the Claimant of the benefit determination no later than 30 days after receipt of a Post-Service Claim. AvMed may extend this period one time for up to 15 additional days if we determine such an extension is necessary due to matters beyond our control and we notify the Claimant, before the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision.
a) If such an extension is necessary because the Claimant failed to provide sufficient information to decide the Claim, the notice of extension will specifically describe the required information, and the Claimant will be afforded at least 45 days from receipt of the notice to provide the specified information.
b) ▇▇▇▇▇'s period for making the benefit determination will be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. If the Claimant fails to supply the requested information within the 45-day period, the Claim will be denied.