Notification of Precertification and Other Pre. Service Claim Determinations a. In the case of an Urgent Care Claim, as soon as possible, taking into account the medical exigencies involved, but not later than seventy-two (72) hours following the Plan’s receipt of the Urgent Care Claim. Similarly, when the Urgent Care Claim seeks to extend a previously approved course of treatment and the request is made at least twenty-four (24) hours prior to the expiration of such previously approved course of treatment, notice of the Plan’s determination will be given to the Member as soon as possible, taking into account the medical exigencies involved, but no later than twenty-four (24) hours following receipt of the request; and b. In the case of a non-urgent care Pre-service Claim, within a reasonable period of time appropriate to the medical circumstances, but not later than fifteen (15) days following the Plan’s receipt of the non-urgent care Pre-service Claim. Notice of the Plan’s approval of a Pre-service Claim will include information sufficient to apprise the Member that the request has been approved. In the event that the Plan renders an adverse determination on a Pre-service Claim, the notification shall include, among other items, the specific reason or reasons for the adverse determination and a statement describing the right of the Member to file an internal appeal or request an external review.
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Samples: Individual Comprehensive Major Medical Preferred Provider Qualified High Deductible Health Plan Subscription Agreement, Individual Comprehensive Major Medical Preferred Provider Subscription Agreement, Individual Comprehensive Major Medical Preferred Provider Subscription Agreement
