Claim Involving Urgent Care definition

Claim Involving Urgent Care means any claim for medical care or treatment that involves an Emergency Case or an Urgent Medical Condition. Whether a claim is a Claim Involving Urgent Care is to be determined by an individual acting on behalf of the Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; however, any claim that a physician with knowledge of the Member's medical condition determines is a Claim Involving Urgent Care shall be treated as a Claim Involving Urgent Care for purposes of these Claims Procedures.
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Claim Involving Urgent Care means any claim for dental care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
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Claim Involving Urgent Care means any claim for dental care or treatment in which the application of the regular time periods to review a denial of a pre-service claim:
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Examples of Claim Involving Urgent Care in a sentence

  • We will provide written confirmation of our decision concerning a Claim Involving Urgent Care within two working days or three calendar days, whichever is less, after providing notification of that decision.

  • An Appointment of Representative form is not required if the Physician is requesting review of an Adverse Benefit Determination relating to a Claim Involving Urgent Care.

  • If the claim is a Claim Involving Urgent Care, you may request an expedited review orally or in writing in which case all necessary information on review may be transmitted between you and us by telephone, facsimile or other available expeditious method.

  • An Appointment of Representative form is not required if your Physician is appealing an Adverse Benefit Determination relating to a Claim Involving Urgent Care.

  • An Appointment of Representative form is not required if the Physician is requesting review of anAdverse Benefit Determination relating to a Claim Involving Urgent Care.

  • In the case of a Claim Involving Urgent Care, the Claimant shall be notified 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 unless the Claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan.

  • Nevertheless, the Plan has established reasonable procedures for determining whether an individual has been authorized to act on behalf of a Claimant, provided that, in the case of a Claim Involving Urgent Care, a Health Care Professional, with knowledge of a Claimant's medical condition shall be permitted to act as the authorized representative of the Claimant.

  • Any request by a Claimant to extend the course of treatment beyond the period of time or number of treatments that is a Claim Involving Urgent Care shall be decided as soon as possible, taking into account the medical exigencies.

  • Except in the case of an Adverse Benefit Determination concerning a Claim Involving Urgent Care, the Plan or the Plan’s Designee shall provide a Claimant with written or electronic Notification of any Adverse Benefit Determination.

  • In the case of an Adverse Benefit Determination by the Plan or the Plan’s Designee concerning a Claim Involving Urgent Care, a description of the expedited review process applicable to such claims.


More Definitions of Claim Involving Urgent Care

Claim Involving Urgent Care means any claim for medical care or treatment in which the application of the regular time period to review a denial of a Pre-service Claim could seriously jeopardize a claimant’s life or health or ability to regain maximum function, or, in the opinion of a physician with knowledge of a claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the requested care or treatment.
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Related to Claim Involving Urgent Care

  • Urgent Care means treatment for a condition that is not a threat to life or limb but does require prompt medical attention. Also, the severity of an urgent condition does not necessitate a trip to the hospital emergency room. An Urgent Care facility is a freestanding facility that is not a physician’s office and which provides Urgent Care.

  • Title IV-E Foster Care means a federal program authorized under §§ 472 and 473 of the Social

  • Urgent Care Claim means a claim for medical care or treatment where making a non-urgent care decision: (a) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, as determined by an individual acting on behalf of the plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; or (b) in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care.

  • Urgent care request means a claim relating to an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, or any Pre-Service Claim or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination:

  • Long-term inpatient care means inpatient services for

  • Investigative consumer report means a consumer report or portion thereof in which information about a natural person's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with the person's neighbors, friends, associates, acquaintances, or others who may have knowledge concerning such items of information.

  • In Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

  • Routine patient care costs means Covered Medical Expenses which are typically provided absent a clinical trial and not otherwise excluded under the Policy. Routine patient care costs do not include:

  • Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

  • Criminal background check means a state criminal background check and a national criminal history check through the Federal Bureau of Investigation.

  • Claims Process means the process pursuant to the BIA by which the Trustee will determine the Proven Claims against the Company.

  • Direct care means medical services, nursing services, or medically-related social services provided to a resident.

  • Automotive hard paste wax means an automotive wax or polish that is:

  • Skilled Nursing Care means services requiring the skill, training or supervision of licensed nursing personnel.

  • Adverse reaction means an unexpected outcome that threatens the health or safety of a patient as a result of a medical service, nursing service, or health-related service provided to the patient.

  • Criminal street gang-related offense means any felony or

  • LOCKHEED XXXXXX Procurement Representative means a person authorized by LOCKHEED XXXXXX'x cognizant procurement organization to administer and/or execute this Contract.

  • Clinical nurse specialist means a registered nurse with relevant post-basic qualifications and 12 months’ experience working in the clinical area of his/her specified post-basic qualification, or a minimum of four years’ post-basic registration experience, including three years’ experience in the relevant specialist field and who satisfies the local criteria.

  • Licensed site remediation professional means an individual

  • Hospice Care means a coordinated program of active professional

  • Pharmacy care means medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.

  • Qualified Medical Child Support Order means a Medical Child Support Order which creates (including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits to which a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined by the Plan Administrator to meet the qualification requirements as outlined under “Procedures” of this provision.

  • Designated chemical dependency specialist means a person

  • Direct Patient Care means the provision of health care services provided directly to individuals being treated for or suspected of having physical or mental illnesses. Direct patient care includes both, face-to-face and telehealth-based preventative care and first-line supervision.

  • Attack directed against any civilian population means a course of conduct involving the multiple commission of acts referred to in paragraph 1 against any civilian population, pursuant to or in furtherance of a State or organizational policy to commit such attack;

  • Non-Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.