Claims Decisions. After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as follows:
Claims Decisions. Claims, disputes and other matters in question between the Contractor and the Owner shall be referred initially to the County Contact Person for review. The County Contact Person shall make a recommendation to the Engineer, and after consultation with all parties, the Engineering will render a decision in writing with reasonable promptness. The decision of the Engineer shall be final and binding.
Claims Decisions. Claims, disputes and other matters in question between the CONTRACTOR and the OWNER shall be referred initially to the OWNER’s Representative for review. The Owner’s Representative shall make a recommendation to the OWNER, and after consultation with all parties, the OWNER will render a decision in writing with reasonable promptness. The decision of the OWNER shall be final and binding.
Claims Decisions. After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as follows: Pre-service claims Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 15 days after the plan receives the claim. This period may be extended by an additional 15 days, if Humana determines the extension is necessary due to matters beyond the control of the plan. Before the end of the initial 15-day period, Humana will notify the Claimant of the circumstances requiring the extension and the date by which Humana expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the necessary information. Urgent-care claims (expedited review) Humana will determine whether a particular claim is an Urgent-care Claim. This determination will be based on information furnished by or on behalf of a covered person. Humana will exercise its judgment when making the determination with deference to the judgment of a physician with knowledge of the covered person's condition. Humana may require a Claimant to clarify the medical urgency and circumstances supporting the Urgent-care Claim for expedited decision-making. Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into account the medical urgency particular to the covered person's situation, but not later than 72 hours after receiving the Urgent-care Claim. If a claim does not provide sufficient information to determine whether, or to what extent, services are covered under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours after receiving the Urgent-care Claim. The notice will describe the specific information necessary to complete the claim. The Claimant will have a reasonable amount of time, taking into account the covered person's circumstances, to provide the necessary information – but not less than 48 hours. Humana will provide notice of the plan's Urgent-care Claim determination as soon as possible but no more than 48 hours after the earlier of: The plan receives the specified information; or The end of the period afforded the Claimant to provide the specified additional information.
Claims Decisions. If the claim is granted, the benefits or relief the Claimant seeks shall be provided. If the claim is wholly or partially denied, the claims official shall, within ninety (90) days (or a longer period, as described above), provide the Claimant with written notice of the denial, setting forth, in a manner calculated to be understood by the Claimant: (1) the specific reason or reasons for the denial; (2) specific references to the provisions on which the denial is based; (3) a description of any additional material or information necessary for the Claimant to perfect the claim, together with an explanation of why the material or information is necessary; and (4) an explanation of the procedures for appealing denied claims. If the Claimant can establish that the claims official has failed to respond to the claim in a timely manner, the Claimant may treat the claim as having been denied by the claims official.
Claims Decisions. If the claim is granted, the benefits or relief the Executive seeks shall be provided. If the claim is wholly or partially denied, the claims official shall, within ninety (90) days (or a longer period, as described above), provide the Executive with written notice of the denial, setting forth, in a manner calculated to be understood by the Executive: (1) the specific reason or reasons for the denial; (2) specific references to the provisions on which the denial is based; (3) a description of any additional material or information necessary for the Executive to perfect the claim, together with an explanation of why the material or information is necessary; and (4) an explanation of the procedures for appealing denied claims. If the Executive can establish that the claims official has failed to respond to the claim in a timely manner, the Executive may treat the claim as having been denied by the claims official.
