Pre-Service Claims. In the case of a Pre-Service Claim, CareFirst shall notify the Member of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim. This period may be extended one time by CareFirst for up to 15 days, provided that such an extension is necessary due to matters beyond the control of CareFirst and CareFirst notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which CareFirst expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member will have at least 45 days from receipt of the notice within which to provide the specified information. In the case of a failure by a Member or authorized representative to follow CareFirst procedures for filing a Pre-Service Claim, the Member or authorized 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 or authorized representative, as appropriate, as soon as possible, but not later than 5 working days following the failure. Notice will be sent within 24 hours in the case of a failure to file a claim involving Urgent/Emergent Care. Notification may be oral, unless written notification is requested by the Member or authorized representative. This paragraph shall apply only in the case of a communication:
a. By a Member or authorized representative that is received by CareFirst or its authorized agent customarily responsible for handling benefit matters; and,
b. That names a specific Member; a specific medical condition or symptom; and a specific treatment, service, or product for which approval is requested. SAMPLE
Pre-Service Claims. In the case of a Pre-Service Claim, the Member shall be notified of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim. This period may be extended one time for up to 15 days, provided that the Plan or the Plan’s Designee both determines that such an extension is necessary due to matters beyond its control, and notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the Notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the Notice within which to provide the specified information. Notification of any Adverse Benefit Determination pursuant to this paragraph shall be made in accordance with paragraph G. herein.
Pre-Service Claims i. I nitial Claim. AvMed will notify the Claimant of the benefit determination with respect to a Pre-Service Claim no later than 15 days after receipt of the Claim. AvMed may extend this period one time for up to 15 additional days, if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision.
1) If such an extension is necessary because the Claimant failed to provide sufficient information to decide the Claim, the notice of extension will specifically describe the required information, and the Claimant will be afforded at least 45 days from receipt of the notice to provide the specified information.
2) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant will be notified of the failure and the proper procedures to be followed, no later than five days following such failure.
3) XxXxx's period for making the benefit determination will be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information. If the Claimant fails to supply the requested information within the 45-day period, the Claim will be denied.
Pre-Service Claims. A Pre-Service Claim is a claim for a benefit under the Plan where the Plan conditions receipt of a benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. Pre-Service Claims are only claims to the extent that precertified services are reviewed and a determination is made regarding the Medical Necessity of the service or the appropriate level of care. Pre-Service Claim determinations do not address a participant’s eligibility or Plan coverage for specific service items. A Pre-Service Urgent Care Claim is any claim for medical care or treatment which respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the participant or the participant’s ability to regain maximum function, or, in the opinion of a physician with knowledge of the participant’s medical condition, would subject the participant to severe pain that cannot be adequately managed without the care or treatment that this the subject of the claim. It is important to remember that, if a participant needs medical care for a condition which could seriously jeopardize his/her life, there is no need to contact the Plan for prior approval. The participant should obtain such care without delay. Further, if the Plan does not require the participant to obtain approval of a medical service prior to getting treatment, then there is no Pre-Service Claim. The participant simply follows the Plan’s procedures with respect to any notice which may be required after receipt of treatment and files the claim as a Post- Service Claim. Please see the Hospital Confinement Review (Precertification) provisions on page 36 for information on when prior approval is required for this plan.
Pre-Service Claims. A determination will be made within 30 days from receipt of your appeal.
Pre-Service Claims. In the case of a Pre-Service Claim, the Reviewing Fiduciary shall notify the claimant, in accordance with the Notice requirements set forth herein, of the benefit determination on review within a reasonable period of time appropriate to the medical circumstances. In case of a Group Health Plan that provides for one appeal of an Adverse Benefit Determination, such Notification shall be provided not later than 30 days after receipt by the Reviewing Fiduciary of the claimant’s request for review of an Adverse Benefit Determination. In case of a Group Health Plan that provides for two appeals of an adverse determination, such Notification shall be provided, with respect to any one of such two appeals, not later than 15 days after receipt by the Reviewing Fiduciary of the claimant’s request for review of the adverse determination.
Pre-Service Claims. In the case of a claim for a benefit not described in (a) or (b) above for which receipt is conditioned upon approval in advance of obtaining medical care (“Pre-Service Claim”), the Board (or its designee) will notify the Claimant of the Fund’s decision within a reasonable period of time but no later than 15 days after the Fund’s receipt of the claim, or 30 days after receipt of the claim if the Board (or its designee) determines that such extension is necessary due to matters beyond control of the Fund. In this circumstance, the Board (or its designee) will, within the initial 15-day period, notify the Claimant of (i) the circumstances requiring the extension of time; (ii) the date by which the Fund expects to render a decision and, if applicable; and
Pre-Service Claims. The term “
Pre-Service Claims
