Urgent Care Claim Sample Clauses

Urgent Care Claim. A Pre-Service claim may also be an Urgent-Care Claim. A Pre-Service claim is considered an Urgent-Care Claim if a delay in receiving the medical services or treatment for which the claim is made:  could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or  in the opinion of a physician with knowledge of the claimant‟s medical condition, could subject the claimant to severe pain that cannot be adequately managed without the services or treatment that is the subject of the claim. A claim that constitutes an Urgent-Care Claim should include information on the medical circumstances that make it an Urgent-Care Claim. The determination of whether a claim for benefits is an Urgent-Care Claim is generally made by the claims administrator based on the information provided with respect to the claim. If a physician with knowledge of the claimant’s medical condition determines that the claim is an Urgent-Care Claim and the claim is filed as an Urgent-Care Claim, the claim will be processed as an Urgent-Care Claim for purposes of the claim and appeal procedures.
Sample 1
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Urgent Care Claim. Those claims that require notification or approval prior to receiving medical care, where a delay in treatment could seriously jeopardize the Covered Person’s life or health or ability to regain maximum function, or in the opinion of a physician with knowledge of the Covered Person’s medical condition could cause severe pain.
Sample 1
Urgent Care Claim i. A determination will be sent to the Member in writing or in electronic form as soon as possible, taking into account the medical exigencies, but no later than seventy-two (72) hours from receipt of the claim.
Sample 1
Urgent Care Claim. The Member may request an expedited appeal of an Urgent Care Claim. This expedited appeal request may be made orally, and the Corporation will communicate with the Member by telephone or facsimile. The Corporation will decide the appeal within a reasonable period of time, taking into account the circumstances, but no later than seventy-two (72) hours after receipt of the request for an expedited appeal.
Sample 1

Related to Urgent Care Claim

  • Urgent Care This plan covers services received at an urgent care center. For other services, such as surgery or diagnostic tests, the amount that you pay is based on the type of service being provided. See Summary of Medical Benefits for details. Follow-up care (such as suture removal or wound care) should be obtained from your primary care provider or specialist.

  • Submitting False Claims The full text of San Francisco Administrative Code Chapter 21, Section 21.35, including the enforcement and penalty provisions, is incorporated into this Agreement. Pursuant to San Francisco Administrative Code §21.35, any contractor or subcontractor who submits a false claim shall be liable to the City for the statutory penalties set forth in that section. A contractor or subcontractor will be deemed to have submitted a false claim to the City if the contractor or subcontractor: (a) knowingly presents or causes to be presented to an officer or employee of the City a false claim or request for payment or approval;

  • Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

  • Submitting False Claims; Monetary Penalties The AOC shall be entitled to remedy any false claims, as defined in California Government Code section 12650 et seq., made to the AOC by the Contractor or any Subcontractor under the standards set forth in Government Code section 12650 et seq. Any Contractor or Subcontractor who submits a false claim shall be liable to the AOC for three times the amount of damages that the AOC sustains because of the false claim. A Contractor or Subcontractor who submits a false claim shall also be liable to the AOC for (a) the costs, including attorney fees, of a civil action brought to recover any of those penalties or damages, and (b) a civil penalty of up to $10,000 for each false claim.

  • False Claim The City reserves the right to recoup benefit payments to any employee who is guilty of submitting a false claim, or abuse of the privileges covered in this section, or working for another employer while on injury leave, and may take disciplinary action.

  • Patient Care Resident shall participate in safe, effective, and compassionate patient care, under supervision, commensurate with Resident's level of advancement and responsibility.

  • How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.

  • Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.

  • Claims Review Population A description of the Population subject to the Claims Review.

  • Hearing Aids Any active employee who is insured under any one of the 9 District sponsored medical plans may request reimbursement for the costs of 10 hearing aids. The maximum amount of reimbursement shall not exceed one 11 thousand dollars ($1,000) within any three (3) year period. The cost of 12 hardware, fitting tests, and other tests related to the hearing aids purchased 13 shall be included for reimbursement purposes. 14

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