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.
Urgent Care Claim. 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.
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.
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.
Urgent Care Claim. We must provide you a determination, based on Medical Necessity, in writing or in electronic form within 72 hours of receipt of the original Urgent Care Claim. An Urgent Care Claim is any claim, where, if the normal Preauthorization review time frames were used, your life, health or ability to regain maximum function could be seriously jeopardized; or you would be subject to severe pain that cannot be adequately managed without the care or treatment. We will defer to the attending Provider with respect to the decision as to whether a claim constitutes “urgent care.” A Provider may be considered an authorized representative without a specific designation by you when the Preauthorization request is for Urgent Care Claims (medical conditions which require immediate treatment). We will notify you or your authorized representative within 24 hours from receipt of the original Urgent Care Claim if we don’t have enough information to make a decision. An extension of 48 hours may be required if we don’t receive complete information in which to make a Medical Necessity decision. If we don’t receive the required information from you within 48 hours after notifying you, we may deny the claim.
Urgent Care Claim. You have 180 days to appeal our decision on an Urgent Care Claim. You may request an expedited review for an Urgent Care Claim either orally or in writing, and all necessary information pertaining to the appeal must be transmitted by telephone, facsimile, or other expeditious method. We must complete the appeal process within 72 hours after receiving the appeal.
