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 Claim means a Claim for Benefits that is treated in an expedited manner because the application of the time periods for making determinations that are not Urgent Care Claims could seriously jeopardize the Member’s life, health or the ability to regain maximum function by waiting for a routine appeal decision. An Urgent Care Claim also means a Claim for Benefits that, in the opinion of a physician with knowledge of the Member’s medical conditions, would subject the Member to severe pain that cannot be adequately managed without the care or the treatment that is the subject of the claim. If an original request for Prior Authorization of an Urgent Care service was denied, the Member could request an Expedited Appeal for the Urgent Care Claim.
Urgent Care Claim means any Claim for Medical Care or treatment where using the timetable for a non-urgent care determination could seriously jeopardize the life or health of the Claimant; or the ability of the Claimant to regain maximum function; or in the opinion of the attending or consulting Physician, would subject the Claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim. A Physician with knowledge of the Claimant’s medical condition may determine if a Claim is one involving Urgent Care. If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine may make the determination.
Examples of Urgent Care Claim in a sentence
Notice of Improperly Submitted ClaimIf a pre-service claim request was not properly submitted, The Plan will notify the Member about the improper submission as soon as practicable, but no later than 3 days after The Plan’s receipt of the claim and will advise the Member of the proper procedures to be followed for filing a pre-service claim.2. Urgent Care Claim Determination and Noticea.
Notice of Improperly Submitted ClaimIf a pre-service claim request was not properly submitted, The Plan will notify the Member about the improper submission as soon as practicable, but no later than 5 days after The Plan’s receipt of the claim, and will advise the Member of the proper procedures to be followed for filing a pre-service claim.2. Urgent Care Claim Determination and Noticea.
If the Member’s Urgent Care Claim is determined to be incomplete, the Member will be sent a notice to this effect within twenty-four (24) hours of receipt of the claim.
The Member may request an expedited appeal of an Urgent Care Claim.
If a Claim is a Pre-Service or Urgent Care Claim, a Health Professional with knowledge of the Member’s Condition will be permitted to act as the Member’s authorized representative, and will be notified of all approvals on the Member’s behalf.
More Definitions of Urgent Care Claim
Urgent Care Claim means any claim with respect to which the application of the time periods for making non-urgent care determinations (1) could, in the opinion of a prudent person with an average knowledge of health or medicine, seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or (2) 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 or treatment that is the subject of the claim.
Urgent Care Claim means a Claim for Benefits that is treated in an expedited manner because the application of the time periods for making determinations that are not Urgent Care Claims could seriously jeopardize the Member’s life, health or the ability to regain maximum function by waiting for a routine appeal decision. An Urgent Care Claim also means a Claim for Benefits that, in the opinion of a Physician with knowledge of the Member’s medical conditions, would subject the Member to severe pain that cannot be adequately managed without the care or the treatment that is the subject of the claim. If an original request for Prior Authorization of an Urgent Care service was denied, the Member could request an Expedited Appeal for the Urgent Care Claim.
Urgent Care Claim means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determination:
Urgent Care Claim means any claim for medical care or treatment where the failure to make a non-urgent care determination quickly (i) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function or
Urgent Care Claim means a Pre-‐Service Claim for medical care or treatment with respect to which the time frame for a non-‐urgent care determination could seriously jeopardize the life or health of the Claimant; or the ability of the Claimant to regain maximum function; or in the opinion of the attending or consulting physician, would subject the Claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim.
Urgent Care Claim means any Claim with respect to which the application of the time periods for making non-urgent care determinations (a) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; 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 or treatment that is the subject of the Claim.)
Urgent Care Claim means any Claim for medical care or treatment for a Condition that could seriously jeopardize the Member’s life or health, or the Member’s ability to regain maximum function or, in the opinion of a Physician with knowledge of the Member’s Condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested.