Common use of Consultation with Medical Professionals Clause in Contracts

Consultation with Medical Professionals. If the claim is, in whole or in part, based on medical judgment, The Plan will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The health care professional will not have been involved in the initial adverse benefit determination. The Member may request information regarding the identity of any health care professional whose advice was obtained during the review of the Member’s claim. The time period for deciding an appeal of an adverse benefit determination and notifying the Member of the final internal adverse benefit determination depends upon the type of claim. The chart below provides the time period in which The Plan will notify the Member of its final internal adverse benefit determination for each type of claim. Urgent Care Claim No later than 72 hours from the date The Plan received the Member’s appeal, taking into account the medical exigency. Pre-Service Claim No later than 30 days from the date The Plan received the Member’s appeal. Post-Service Claim No later than 60 days from the date The Plan received the Member’s appeal. Concurrent Care Claim • If the Member’s claim involved Urgent Care, no later than 72 hours from the date The Plan received the Member’s appeal, taking into account the medical exigency. • If the Member’s claim did not involve Urgent Care, the time period for deciding a pre-service (non-urgent care) claim or a post-service claim, as applicable, will govern. Rescission Claim No later than 60 days from the date The Plan received the Member’s appeal.