Common use of Claims for Benefits Clause in Contracts

Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is an Urgent Care or Pre-Service Claim, a Health Professional with knowledge of the Member’s Condition shall be permitted to act as the Member’s authorized representative and will be notified of all approvals on the Member’s behalf. a. Pre-Service Claims. i. Initial Claim. 1) AvMed shall notify the Claimant of the benefit determination with respect to a Pre-Service Claim not later than 15 days after receipt of the Claim. 2) AvMed may extend this period one time for up to 15 days, if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant, before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. a) If such an extension is necessary because the Claimant failed to submit the information required to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice to provide the specified information. b) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed, not later than five days following such failure. c) XxXxx's period for making the benefit determination shall be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. 3) If the Claimant fails to supply the requested information within the 45-day period, the Claim shall be denied.

Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is an Urgent Care or Pre-Service Claim, a Health Professional with knowledge of the Member’s Condition shall be permitted to act as the Member’s authorized representative and will be notified of all approvals on the Member’s behalf. a. Pre-Service Claims. i. Initial Claim. 1) AvMed shall notify the Claimant of the benefit determination with respect to a Pre-Service Claim not later than 15 days after receipt of the Claim. 2) AvMed may extend this period one time for up to 15 days, if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant, Claimant before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. a) If such an extension is necessary because the Claimant failed to submit the information required to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice to provide the specified information. b) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed, not later than five days following such failure. c) XxXxx's period for making the benefit determination shall be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. 3) If the Claimant fails to supply the requested information within the 45-45 day period, the Claim shall be denied.

Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is an Urgent Care or Pre-Service Claim, a Health Professional with knowledge of the Member’s Condition shall be permitted to act as the Member’s authorized representative representative, and will be notified of all approvals on the Member’s behalf. a. Pre-Service Claims. i. Initial Claim. 1) AvMed shall notify the Claimant of the benefit determination with respect to a Pre-Service Claim not later than 15 days after receipt of the Claim. 2) AvMed may extend this period one time time, for up to 15 days, if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant, before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. a) If such an extension is necessary because the Claimant failed to submit the information required to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice to provide the specified information. b) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant shall be notified of the failure failure, and the proper procedures to be followed, not later than five days following such failure. c) XxXxx's period for making the benefit determination shall be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. 3) If the Claimant fails to supply the requested information within the 45-45 day period, the Claim shall be denied.

Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is an Urgent Care or Pre-Service Claim, a Health Professional with knowledge of the Member’s Condition shall be permitted to act as the Member’s authorized representative representative, and will be notified of all approvals on the Member’s behalf. a. Pre-Service Claims. i. Initial Claim. 1) AvMed shall notify the Claimant of the benefit determination with respect to a Pre-Service Claim not later than 15 days after receipt of the Claim. 2) AvMed may extend this period one time time, for up to 15 days, days if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant, before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. a) If such an extension is necessary because the Claimant failed to submit the information required to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice to provide the specified information. b) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant shall be notified of the failure failure, and the proper procedures to be followed, not later than five days following such failure. c) XxXxx's period for making the benefit determination shall be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. 3) If the Claimant fails to supply the requested information within the 45-45 day period, the Claim shall be denied.