Common use of Pre-Service Claims Clause in Contracts

Pre-Service Claims. In the case of a Pre-Service Claim, CareFirst BlueChoice shall notify the Member of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim. This period may be extended one time by CareFirst BlueChoice for up to 15 days, provided that such an extension is necessary due to matters beyond the control of CareFirst BlueChoice and CareFirst BlueChoice notifies the Member, prior to the expiration of the initial 15-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 will have at least 45 days from receipt of the notice within which to provide the specified information. In the case of a failure by a Member or authorized representative to follow CareFirst BlueChoice procedures for filing a Pre-Service Claim, the Member or authorized representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Member or authorized representative, as appropriate, as soon as possible, but not later than 5 working days following the failure. Notice will be sent within 24 hours in the case of a failure to file a claim involving Urgent/Emergent Care. Notification may be oral, unless written notification is requested by the Member or authorized representative. This paragraph shall apply only in the case of a communication:

Pre-Service Claims. In the case of a Pre-Service Claim, CareFirst BlueChoice shall notify the Member of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim. This period may be extended one time by CareFirst BlueChoice for up to 15 days, provided that such an extension is necessary due to matters beyond the control of CareFirst BlueChoice and CareFirst BlueChoice notifies the Member, prior to the expiration of the initial 15-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 will have at least 45 days from receipt of the notice within which to provide the specified information. In the case of a failure by a Member or authorized representative to follow CareFirst BlueChoice procedures for filing a Pre-Service Claim, the Member or authorized representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Member or authorized representative, as appropriate, as soon as possible, but not later than 5 working days following the failure. Notice will be sent within 24 hours in the case of a failure to file a claim involving Urgent/Emergent Care. Notification may be oral, unless written notification is requested by the Member or authorized representative. This paragraph shall apply only in the case of a communication:: SAMPLE

Pre-Service Claims. In the case of a Pre-Service Claim, CareFirst BlueChoice the Organization shall notify the Member claimant of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but no not later than 15 days after receipt of the claimclaim by the Organization. This period may be extended one time by CareFirst BlueChoice the Organization for up to 15 days, provided that the Organization determines that such an extension is necessary due to matters beyond the control of CareFirst BlueChoice the Organization and CareFirst BlueChoice notifies the Memberclaimant, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which CareFirst BlueChoice the Organization expects to render a decision. If such an extension is necessary due to a failure of the Member claimant to submit the information necessary to decide the claim, the notice Notice of extension shall specifically describe the required information, and the Member will have claimant shall be afforded at least 45 days from receipt of the notice Notice within which to provide the specified information. In 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. Notwithstanding the above, in the case of a failure by a Member claimant or an authorized representative of a claimant to follow CareFirst BlueChoice the Plan’s procedures for filing a Pre-Service Claim, the Member claimant or authorized representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification Notification shall be provided to the Member claimant or authorized representative, as appropriate, as soon as possible, but not later than 5 working days following the failure. Notice will be sent within (24 hours in the case of a failure to file a claim involving Urgent/Emergent Claim Involving Urgent Care) following the failure. Notification may be oral, unless written notification Notification is requested by the Member claimant or authorized representative. This paragraph shall apply only in the case of a communicationfailure that:

Pre-Service Claims. In the case of a Pre-Service Claim, CareFirst BlueChoice shall notify the Member of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but no later than 15 fifteen (15) days after receipt of the claim. This period may be extended one time by CareFirst BlueChoice for up to 15 fifteen (15) days, provided that such an extension is necessary due to matters beyond the control of CareFirst BlueChoice and CareFirst BlueChoice notifies the Member, prior to the expiration of the initial fifteen (15-) 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 will have at least 45 forty-five (45) days from receipt of the notice within which to provide the specified information. In the case of a failure by a Member or authorized representative to follow CareFirst BlueChoice procedures for filing a Pre-Service Claim, the Member or authorized representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Member or authorized representative, as appropriate, as soon as possible, but not later than 5 five (5) working days following the failure. Notice will be sent within 24 twenty-four (24) hours in the case of a failure to file a claim involving UrgentXxxxxx/Emergent Care. Notification may be oral, unless written notification is requested by the Member or authorized representative. This paragraph shall apply only in the case of a communication: