Manner and Content of Initial Claims Determination Notification. AvMed will provide a Claimant with written or electronic notification of any Adverse Benefit Determination. The notification will set forth the following, in a manner calculated to be understood by the Claimant:
a. sufficient information to identify the Claim, including (as applicable) the date of service, Health Care Provider, and Claim amount, as well as notice that the diagnosis and treatment codes, along with the corresponding meaning, are available free of charge upon request;
b. the specific reason for the Adverse Benefit Determination including the denial code and its corresponding meaning;
c. reference to the specific Contract provisions on which the determination is based;
d. a description of any additional material or information necessary for the Claimant to perfect the Claim and an explanation of why such material or information is necessary;
e. a description of AvMed’s review procedures and the applicable time limits;
f. in the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description of the expedited review process applicable to such Claim;
g. any internal rule, guideline, protocol or other similar criterion relied upon in making the Adverse Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge to the Claimant upon request;
h. if the Adverse Benefit Determination is based on whether the treatment or service is Experimental or Investigational, or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the terms of this Contract to the Member’s medical circumstances; or a statement that such explanation will be provided free of charge upon request.
