Service Claims. Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 15 days after the plan receives the claim. This period may be extended by an additional 15 days, if Humana determines the extension is necessary due to matters beyond the control of the plan. Before the end of the initial 15-day period, Humana will notify the Claimant of the circumstances requiring the extension and the date by which Humana expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the necessary information. Urgent-care Claims (expedited review) Humana will determine whether a particular claim is an Urgent-care Claim. This determination will be based on information furnished by or on behalf of a covered person. Humana will exercise its judgment when making the determination with deference to the judgment of a physician with knowledge of the covered person's condition. Humana may require a Claimant to clarify the medical urgency and circumstances supporting the Urgent-care Claim for expedited decision-making. Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into account the medical urgency particular to the covered person's situation, but not later than 72 hours after receiving the Urgent-care Claim. If a claim does not provide sufficient information to determine whether, or to what extent, services are covered under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours after receiving the Urgent-care Claim. The notice will describe the specific information necessary to complete the claim. The Claimant will have a reasonable amount of time, taking into account the covered person's circumstances, to provide the necessary information - but not less than 48 hours. Humana will provide notice of the plan's Urgent-care Claim determination as soon as possible but no more than 48 hours after the earlier of: • The plan receives the specified information; or • The end of the period afforded the Claimant to provide the specified additional information.
Service Claims. Aetna will notify the covered person of a post-service claim decision as soon as possible, but not later than 30 calendar days after the claim is made. Aetna may determine that due to matters beyond its control an extension of this 30 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 30 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 patient will have 45 calendar days, from the date of the notice, to provide Aetna with the required information. Concurrent Care Claim Extension Following a request for a concurrent care claim extension, Aetna will notify the covered person of a claim decision for urgent care as soon as possible but not later than 24 hours, provided the request is received at least 24 hours prior to the expiration of the approved course of treatment. A decision will be provided not later than 15 calendar days with respect to all other care, following a request for a concurrent care claim extension.
Service Claims. Aetna shall issue a decision within 30 calendar days of receipt of the request for a Level Two appeal. Exhaustion of Process Aetna encourages covered persons to exhaust the applicable Level One and Level Two processes of the Appeal Procedure before they: • Contact the Connecticut Department of Insurance to request an investigation of a complaint or appeal; or • File a complaint or appeal with the Connecticut Department of Insurance; or • Establish any: − litigation; − arbitration; or − administrative proceeding; regarding an alleged breach of the policy terms by Aetna Life Insurance Company; or any matter within the scope of the Appeals Procedure. Under certain circumstances the covered person may seek simultaneous review through the internal Appeals Procedure and External Review processes—these include Urgent Care Claims and situations where the covered person is receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure is not required under these circumstances. The covered person may contact the Department of Insurance for assistance regarding any Complaint/Grievance or Appeal at the following address: State of Connecticut Insurance Department Consumer Affairs Department P.O. Box 816 Hartford, CT 06142-0816 0-000-000-0000 or 1-800-203-3447 xxx.xx@xx.xxx Or, the Office of Healthcare Advocate, at: State of Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 1-866-297-3992 Xxxxxxxxxx.xxxxxxxx@xx.xxx External Review The covered person may receive an adverse benefit determination or final adverse benefit determination. In these situations, the covered person may request an External Review if they or their provider disagrees with Aetna’s decision. To request an External Review, any of the following requirements must be met: • The covered person has received an adverse benefit determination notice by Aetna, and Aetna did not adhere to all claim determination and appeal requirements of the Federal Department of Health and Human Services. • The covered person has received a final adverse benefit determination notice by Aetna. • The covered person qualifies for a faster review as explained below. • As to dental, vision and hearing claims only, the cost of the initial service, supply or treatment in question for which the covered person is responsible exceeds $500. The notice of adverse benefit determination or final adverse benefit determination that the covered person receives from Aetna will...
Service Claims a. All service coverage claims must be submitted in writing to FirstMile according to the FirstMile Claims Policy, incorporated herein by reference.
Service Claims. If services provided are in connection with a problem that is covered by a Third Party Warranty, then such services shall not be billed out at Seller’s then-prevailing hourly rate, to the extent of the Third Party Warranty coverage. Please refer to your manufacturer or third party provided documentation for scope of such warranty coverage. Any labor or travel provided that is not covered under the Third Party Warranty or where services provided are not covered under a Third Party Warranty then such services and all labor and travel will be billed out at Seller’s then-prevailing hourly rate.
Service Claims. Pre-Service Claims are requests that the Health Plan provide or pay for a Service that you have not yet received. Our clinical peer will decide if your claim involves an Urgent Medical Condition or not. If you receive any of the Services you are requesting before we make our decision, your claim or Appeal will become a Post-Service Claim with respect to those Services. If you have any questions about Pre-Service Claims, please contact Member Services Monday through Friday between 7:30 a.m. and 9 p.m. at 0-000-000-0000 or 711 (TTY) . Procedure for Making a Non-Urgent Pre-Service Claim
Service Claims. Post-Service claims are requests for payment for Services you already received, including claims for Emergency Services and Urgent Care Services rendered outside of our Service Area. If you have any questions about Post-Service claims or Appeals, please contact Member Services Monday through Friday between 7:30 a.m. and 9 p.m. at 0-000-000-0000 or 711 (TTY) . Procedure for Making a Post-Service Claim Claims for Emergency Services or Urgent Care Services rendered outside of our Service Area or other Services received from non-Plan Providers must be filed on forms provided by the Health Plan; such forms may be obtained on our website, xxx.xx.xxx or by contacting Member Services Monday through Friday between 7:30 a.m. and 9 p.m. at 0-000-000-0000 or 711 (TTY).
Service Claims. Notwithstanding the foregoing or anything to the contrary in Section 3.1 above, following the Closing, upon the written request of Seller, Purchaser shall, to the extent reasonably practical, process and service the claims under any of the following liabilities of Seller (collectively, “Service Claims” and each a “Service Claim”): (a) support and service obligations of Seller under Maintenance and Support Contracts listed on Schedule 6.11; or (b) liabilities under Open Customer Contracts that are not expressly assumed under Section 3.1 as “Assumed Liabilities”. Purchaser shall process and service such Service Claims in a reasonable manner consistent with its service level agreements or commitments provided to other customers of the Purchaser or Sphere 3D’s business (which shall be based on standard industry practices) and in accordance with the applicable Contract terms and conditions. To the extent Purchaser processes any such Service Claim, Seller shall during the Earn-Out Period reimburse Purchaser for the Service Costs incurred by Purchaser or any of its Affiliates in the handling of such Service Claims to the extent that the aggregate Service Costs, calculated based on market rates of the Purchaser, exceed the Service Claim Threshold and subject to a reasonable time for Seller to review such request for reimbursement. For purposes of this Agreement, “Service Costs” means the reasonable costs actually incurred by Seller or any of its Affiliates in fulfilling Purchaser’s obligations under Section 3.2(b) and this Section 8.14, including a reasonable application of overhead costs. Nothing herein shall limit or restrict Seller’s rights or abilities to contract our outsource with a third party to process and service such Service Claims, provided that Seller shall be solely responsible for any and all costs, fees or other payment liabilities of such third party arrangements.
Service Claims. An initial determination will be made within 15 days from receipt of your claim. If additional time is necessary, the Plan may take up to 15 additional days, due to matters beyond the control of the Plan; you will be informed of the extension within this 15-day deadline. In addition, if additional information is needed to process your claim, you will be notified within 15 days of receipt of your claim and you then have up to 45 days to provide the requested information. After 45 days or, if sooner, after the information is received, the Plan will make a determination within 15 days. If you improperly file a pre-service claim, you will be notified as soon as possible, but no later than five days after receiving the claim. The notice will describe the proper procedures for filing a pre-service claim. You must re-file the claim to begin the pre-service claim determination process. • Post-Service Claims. An initial determination will be made within 30 days from receipt of your claim. If additional time is necessary, the Plan may take up to 15 additional days, due to matters beyond the control of the Plan; you will be informed of the extension within this 15-day deadline. In addition, if additional information is needed to process your claim, you will be notified within 30 days of receipt of your claim and you then have up to 45 days to provide the requested information. After 45 days or, if sooner, after the information is received, the Plan will make a determination within 15 days. • Concurrent Claims. Concurrent claims, which involve terminating or reducing a benefit, will be made as soon as possible and early enough to allow you to have an appeal decided before the benefit is reduced or terminated. Concurrent claims constitute a request for an appeal of an adverse benefit determination. Concurrent claims must be made in writing, except that concurrent claims that are also urgent claims may be made orally and followed up with a written claim. For claims that involved the extension of an approved urgent care treatment, the Fund will respond within 24 hours of receipt, provided the claim is received at least 24 hours before the expiration of an approved treatment. Concurrent claims and determinations involving urgent care may both be provided orally and confirmed in writing. A request to extend approved treatment that does not involve urgent care will be decided according to pre-service or post-service claim timeframes. Health care claims will generally be pai...
Service Claims. Aetna shall issue a decision within 30 calendar days of receipt of the request for an appeal. You may submit written comments, documents, records and other information relating to your claim, whether or not the comments, documents, records or other information were submitted in connection with the initial claim. A copy of the specific rule, guideline or protocol relied upon in the adverse benefit determination will be provided free of charge upon request by you or your authorized representative. You may also request that the Plan provide you, free of charge, copies of all documents, records and other information relevant to the claim. Level Two Appeal If Aetna upholds an adverse benefit determination at the first level of appeal, you or your authorized representative have the right to file a level two appeal. The appeal must be submitted within 60 calendar days following the receipt of notice of a level one appeal. A level two appeal of an adverse benefit determination of an urgent care claim, a Pre-Service Claim, or a Post- Service Claim shall be provided by Aetna personnel not involved in making an adverse benefit determination. Urgent Care Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 36 hours of receipt of the request for a level two appeal. Pre-Service Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 15 calendar days of receipt of the request for level two appeal.
