Common use of Concurrent Care Determination and Time Frame for Decision and Notice Clause in Contracts

Concurrent Care Determination and Time Frame for Decision and Notice. a. Request for Extension of Previously Approved Time Period or Number of Treatments 1. In response to the Member’s claim for an extension of a previously approved time period for treatments or number of treatments, and if the Member’s claim involves Urgent Care, The Plan will review the claim and notify the Member of its determination no later than 24 hours from the date The Plan received the Member’s claim, provided the Member’s claim was filed at least 24 hours prior to the end of the approved time period or number of treatments. 2. If the Member’s claim was not filed at least 24 hours prior to the end of the approved time period or number of treatments, the Member’s claim will be treated as and decided within the timeframes for an Urgent Care claim as described in the section entitled Initial Claim Determination by Type of Claim. 3. If the Member’s claim did not involve Urgent Care, the time periods for deciding pre-service claims and post- service claims, as applicable, will govern. b. Reduction or Termination of Ongoing Course of Treatment Other than through a Plan amendment or termination, The Plan may not subsequently reduce or terminate an ongoing course of treatment for which the Member has received prior approval unless The Plan provides the Member with written notice of the reduction or termination and the scheduled date of its occurrence sufficiently in advance to allow the Member to appeal the determination and obtain a decision before the reduction or termination occurs.