Pre-Service Claim Sample Clauses

Pre-Service Claim. A pre-service claim is a claim that requires pre-approval as a condition of coverage. Approval or denial of an initial pre-service claim will be sent to a claimant within 15 calendar days after receipt of the claim, unless an extension is required. The 15-day period may be extended once up to 15 calendar days. A claimant will be notified of any such extension before the expiration of the initial 15 day period. If the extension is required due to a claimant's failure to provide the necessary information, the Claims Administrator will describe the required information. A claimant will have at least 45 calendar days from receipt of the notice to provide the information. If a claimant fails to follow the Plan's procedures for filing a pre-service claim, the Claims Administrator will notify such claimant of such failure no later than 5 days (24 hours if the pre-service claim also is an urgent care claim) following receipt of the claim. The preceding sentence only will apply in the case of a claim that (i) is received by the person responsible for handling benefit matters; and (ii) names a specific claimant, a specific medical condition or symptom and a specific treatment, service or product.
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Pre-Service Claim. A Pre-Service Claim is a claim for benefits, that is filed before the medical services or treatment is provided.
Sample 1
Pre-Service Claim. The Corporation will decide the appeal within a reasonable period of time, taking into account the circumstances, but no later than fifteen (15) days after receipt of the appeal. If the Member disagrees with the Corporation’s decision, the Member can submit a second appeal within ninety (90) days after receipt of the final decision of the first appeal. The Corporation will decide the second appeal within a reasonable period of time, taking into account the circumstances, but no later than fifteen (15) days after receipt of the second appeal.
Sample 1

Related to Pre-Service Claim

  • Post Service Claims In the case of a Post-Service Claim, CareFirst BlueChoice shall notify the Member of the CareFirst BlueChoice’s Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after receipt of the claim. This period may be extended one time by CareFirst BlueChoice for up to 15 days, provided that CareFirst BlueChoice both determines that such an extension is necessary due to matters beyond the control of CareFirst BlueChoice and notifies the Member, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which CareFirst BlueChoice expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information.

  • Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • Core Services The Company agrees to provide those Core Services to the Municipality as set forth in Schedule “A” and further agrees to the process contained in Schedule “A”.

  • Future Services The Consultant acknowledges each of the following with regard to performing future services for the City: • The Consultant’s performance of Work in an Approved Service Order may create an actual or appearance of a conflict of interest with regard to the Consultant performing or participating in the performance of some related future services, particularly when the Work in an Approved Service Order comprises one element or aspect of a multi- phase process or project; • Such an actual or appearance of a conflict of interest would be a ground for the City to disqualify the Consultant from performing or participating in the performance of such future services; and • The Consultant is solely responsible for considering what potential conflicts of interest, if any, performing Work in an Approved Service Order might have on its ability to obtain contracts to perform future services.

  • Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:

  • Year-End Grievance In the event a grievance is filed at such time that it cannot be processed through all steps in this grievance procedure by the end of the school year and, if left unresolved until the beginning of the following school year, could result in irreparable harm to a party in interest, the time limits set forth herein shall be reduced so that the grievance procedure may be exhausted prior to the end of the school year or within a maximum of 30 days thereafter. Reduction of the time limit shall be with mutual consent.

  • Group Grievance Where a number of employees have identical grievances and each employee would be entitled to grieve separately they may present a group grievance in writing signed by each employee who is grieving to the Administrator or her designate within ten (10) days after the circumstances giving rise to the grievance have occurred or ought reasonably to have come to the attention of the employee(s). The grievance shall then be treated as being initiated at Step No. 1 and the applicable provisions of this Article shall then apply with respect to the processing of such grievance.

  • Grievance Procedure - Individual In the case of a grievance by the Bargaining Unit on behalf of one of its Members, the following steps may be taken in sequence where informal attempts to resolve the matter with the immediate supervisor have failed.

  • Acupuncture Services Benefits will be provided for Medically Necessary acupuncture services when provided by a provider licensed to perform such services.

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