CLAIMS PROCEDURES COMPLIANCE. SAMPLE 1. Failure to follow Pre-Service Claims Procedures. In the case of a failure by a Member or a Member’s Representative to follow the Plan’s procedures for filing a Pre-Service Claim the Member or representative shall be notified of the failure and the proper procedures to be followed in filing a Claim for Benefits. This Notification shall be provided to the Member, the Member’s Representative, or Health Care Provider acting on behalf of the Member, as appropriate, as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a Claim Involving Urgent Care) following the failure. Notification may be oral, unless written Notification is requested by the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member. The above shall apply only in the case of a failure that: a. Is a communication by a Member, the Member’s Representative, or Health Care Provider acting on behalf of the Member that is received by the person or organizational unit designated by the Plan or Plan Designee that handles Claims for Benefits; and b. Is a communication that names a specific Member; a specific medical condition or symptom; and a specific treatment, service, or product for which approval is requested.
Appears in 6 contracts
Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, In Network Individual Enrollment Agreement
CLAIMS PROCEDURES COMPLIANCE. SAMPLE
1. Failure to follow Pre-Service Claims Procedures. In the case of a failure by a Member or a Member’s Member‟s Representative to follow the Plan’s Plan‟s procedures for filing a Pre-Service Claim the Member or representative shall be notified of the failure and the proper procedures to be followed in filing a Claim for Benefits. This Notification shall be provided to the Member, the Member’s Member‟s Representative, or Health Care Provider acting on behalf of the Member, as appropriate, as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a Claim Involving Urgent Care) following the failure. Notification may be oral, unless written Notification is requested by the Member, the Member’s Member‟s Representative or Health Care Provider acting on behalf of the Member. The above shall apply only in the case of a failure that:
a. Is a communication by a Member, the Member’s Member‟s Representative, or Health Care Provider acting on behalf of the Member that is received by the person or organizational unit designated by the Plan or Plan Designee that handles Claims for Benefits; and
b. Is a communication that names a specific Member; a specific medical condition or symptom; and a specific treatment, service, or product for which approval is requested.
Appears in 3 contracts
Samples: In Network Group Contract, In Network Group Contract, In Network Group Contract
