Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. With enough advance notice to allow the Member to file an Appeal. If the Member files an Appeal, Covered Benefits under the Certificate will continue for the previously approved course of treatment until a final Appeal decision is rendered. During this continuation period, the Member is responsible for any Copayments that apply to the services; supplies; and treatment; that are rendered in connection with the claim that is under Appeal. If HMO's initial claim decision is upheld in the final Appeal decision, the Member will be responsible for all charges incurred for services; supplies; and treatment; received during this continuation period. Post-Service Claim. A claim for a benefit that is not a pre-service claim. Within 30 calendar days. HMO 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 HMO notifies the Member within the first 30 calendar day period. If this extension is needed because HMO needs more information to make a claim decision, the notice of the extension shall specifically describe the required information. The Member will have 45 calendar days, from the date of the notice, to provide HMO with the required information.
Concurrent Care Claim Reduction or Termination. A decision to reduce or terminate a course of treatment that was previously approved.
Concurrent Care Claim Reduction or Termination. Aetna will notify the covered person of a claim decision to reduce or terminate a previously approved course of treatment with enough time for the covered person to file an appeal. If the covered person files an appeal, coverage under the plan will continue for the previously approved course of treatment until a final appeal decision is rendered. During this continuation period, the covered person is responsible for any copayments; coinsurance; and deductibles; that apply to the services; supplies; and treatment; that are rendered in connection with the claim that is under appeal. If Aetna's initial claim decision is upheld in the final appeal decision, the covered person will be responsible for all charges incurred for services; supplies; and treatment; received during this continuation period.
Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. Post-Service Claim. A claim for a benefit that is not a pre- service claim. If an urgent care claim, as soon as possible but not later than 24 hours. Otherwise, within 15 calendar days With enough advance notice to allow the Member to Appeal. Within 30 calendar days
Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. Post-Service Claim. A claim for a benefit that is not a pre- service claim. As soon as possible but not later than 24 hours Within 15 calendar days If an urgent care claim, as soon as possible but not later than 24 hours. Otherwise, within 15 calendar days With enough advance notice to allow the Member to Appeal. Within 14 business days for a claim that involves Utilization Review. Otherwise, within 30 calendar days COMPLAINTS AND APPEALS HMO has procedures for Members to use if they are dissatisfied with a decision that the HMO has made or with the operation of the HMO. The procedure the Member needs to follow will depend on the type of issue or problem the Member has. • Appeal. An Appeal is a request to the HMO to reconsider an adverse benefit determination. The Appeal procedure for an adverse benefit determination has two levels. • Complaint. A Complaint is an expression of dissatisfaction about quality of care or the operation of the HMO.
Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. Post-Service Claim. A claim for a benefit that is not a pre- service claim. As soon as possible but not later than 72 hours. Within 2 business days of a request for preauthorization for a treatment, procedure, drug or device (unless additional information is required). Within 24 hours of a request for preadmission. If an urgent care claim, as soon as possible but not later than 24 hours. Within 24 hours of preauthorization of treatment during a hospitalization. Within 24 hours of receipt of a request for review of a Member’s continued Hospital stay and prior to the time when a previous authorization for Hospital care will expire Within 20 business days. COMPLAINTS AND APPEALS HMO has procedures for Members to use if they are dissatisfied with a decision that the HMO has made or with the operation of the HMO. The procedure the Member needs to follow will depend on the type of issue or problem the Member has. If the state of Kentucky requirements are more beneficial to the Member, the state requirements will govern. • Appeal. An Appeal is a request to the HMO to reconsider an adverse benefit determination. • Complaint. A Complaint is an expression of dissatisfaction about quality of care or the operation of the HMO.
Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. With enough advance notice to allow the Member to Appeal. Post-Service Claim. A claim for a benefit that is not a pre-service claim. Within 30 calendar days. COMPLAINTS AND APPEALS HMO has procedures for Members to use if they are dissatisfied with a decision that the HMO has made or with the operation of the HMO. The procedure the Member needs to follow will depend on the type of issue or problem the Member has. • Appeal. An Appeal is a request to the HMO to reconsider an adverse benefit determination. The Appeal procedure for an adverse benefit determination has two levels. • Complaint. A Complaint is an expression of dissatisfaction about quality of care or the operation of the HMO. The Complaint procedure may, if the Member chooses, follow the same path as an Adverse Benefit Determination.
Concurrent Care Claim Reduction or Termination. A decision to reduce or terminate a previously approved course of treatment. Pre-Service Claim: Any claim for medical care or treatment that requires approval before the medical care or treatment is received. Post-Service Claim: Any claim that is not a “Pre-Service Claim.” Urgent Care Claim: Any claim for medical care or treatment in which a delay in treatment could: jeopardize your life; jeopardize your ability to regain maximum function; cause you to suffer severe pain that cannot be adequately managed without the requested medical care or treatment; or In the case of a pregnant woman, cause serious jeopardy to the health of the fetus. Claim Determinations Urgent Care Claims Aetna will make notification of an urgent care claim determination as soon as possible but not more than 72 hours after the claim is made. If more information is needed to make an urgent claim determination, Aetna will notify the claimant within 24 hours of receipt of the claim. The claimant has 48 hours after receiving such notice to provide Aetna with the additional information. Aetna will notify the claimant within 48 hours of the earlier of the receipt of the additional information or the end of the 48 hour period given the physician to provide Aetna with the information. If the claimant fails to follow plan procedures for filing a claim, Aetna will notify the claimant within 24 hours following the failure to comply. Pre-Service Claims Aetna will make notification of a claim determination as soon as possible but not later than 15 calendar days after the pre-service claim is made. Aetna may determine that due to matters beyond its control an extension of this 15 calendar days claim determination period is required. Such an extension, of not longer than 15 additional calendar days, will be allowed if Aetna notifies you within the first 15 calendar days period. If this extension is needed because Aetna needs additional information to make a claim determination, the notice of the extension shall specifically describe the required information. You will have 45 calendar days, from the date of the notice, to provide Aetna with the required information. Post-Service Claims Aetna will make notification of a claim determination as soon as possible but not later than 30 calendar days after the post-service claim is made. Aetna may determine that due to matters beyond its control an extension of this 30 calendar day claim determination period is required. Such an extension, of not lo...
Concurrent Care Claim Reduction or Termination. Aetna will make notification of a claim determination to reduce or terminate a previously approved course of treatment with enough time for you to file an appeal.
