Appeal of an Urgent Care Claim Sample Clauses
The "Appeal of an Urgent Care Claim" clause outlines the process by which a claimant can challenge the denial or reduction of a claim related to urgent medical care. Typically, this clause sets forth expedited timelines and procedures to ensure that appeals are reviewed and resolved quickly, often within a matter of days, due to the time-sensitive nature of urgent care. Its core function is to provide a rapid mechanism for resolving disputes over urgent care coverage, ensuring that individuals receive timely access to necessary medical treatment without undue administrative delays.
Appeal of an Urgent Care Claim. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim within 365 days of receiving the Adverse Benefit Determination. AvMed will review the Claim and notify the Claimant of its benefit determination on review as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the Claimant’s request; except in limited cases when AvMed provides new information to the Claimant that AvMed is considering in the appeal, and gives the Claimant an opportunity to respond. An appeal of an Adverse Benefit Determination with respect to an Urgent Care Claim may be submitted to AvMed’s Member Engagement Center at the address listed under Appeal of a Pre-Service Claim, above.
Appeal of an Urgent Care Claim. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim within 365 days of receiving the Adverse Benefit Determination.
1) AvMed shall notify the Claimant of the benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the Claimant’s request. An appeal of an Adverse Benefit Determination with respect to an Urgent Care Claim may be submitted to AvMed’s Member Relations Department at the address listed in Section 13.3a.ii.