Appeal Response Timeframes Sample Clauses

Appeal Response Timeframes. In the case of a Claim involving Urgent Care as defined below, We will expedite the review process. The Member may request an expedited review orally or in writing. All necessary information may be transmitted between the parties by telephone, facsimile, or other available similarly expeditious means. We will review the Member’s Appeal promptly. The Member will receive notice of Our review decision for: (1) Urgent Care Claims as soon as reasonably possible taking into account medical exigencies, but not later than seventy-two (72) hours after We receive the Member’s request for an Appeal of an adverse Benefit determination. (“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.)