Claim Involving Urgent Care definition

Claim Involving Urgent Care means any claim for medical care or treatment that involves an Emergency Case or an Urgent Medical Condition. Whether a claim is a Claim Involving Urgent Care is to be determined by an individual acting on behalf of the Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; however, any claim that a physician with knowledge of the Member's medical condition determines is a Claim Involving Urgent Care shall be treated as a Claim Involving Urgent Care for purposes of these Claims Procedures.
Sample 1Sample 2Sample 3
Claim Involving Urgent Care means any claim for dental care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
Sample 1Sample 2Sample 3
Claim Involving Urgent Care means any claim for dental care or treatment in which the application of the regular time periods to review a denial of a pre-service claim:
Sample 1Sample 2Sample 3

Examples of Claim Involving Urgent Care in a sentence

  • In the case of a Claim Involving Urgent Care, the Member shall be notified of the benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 24 hours after receipt of the claim unless the Member fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan.

  • If your health care practitioner (as defined in Ohio Revised Code 3923.041(A)) uses Medical Mutual's electronic software system to request an appeal of a Claim Involving Urgent Care, Medical Mutual will respond to the appeal within 48 hours of receipt.

  • The evaluation criteria for the members of the Executive Committee are measurable and pre-designed, globally considering the Company’s growth and wealth creation in a mid-long term perspective.

  • If the request for an extension is for a Claim Involving Urgent Care, Capital Health Plan will use its best efforts to notify the Member of the approval or denial of such requested extension within 24 hours after receipt of the request, provided it is received at least 24 hours prior to the expiration of the previously approved number of visits or length of coverage for such Services.

  • Nevertheless, the Plan has established reasonable procedures for determining whether an individual has been authorized to act on behalf of a Claimant, provided that, in the case of a Claim Involving Urgent Care, a Health Care Professional, with knowledge of a Claimant's medical condition shall be permitted to act as the authorized representative of the Claimant.

  • Benefit Determinations on Pre-Service Claims Involving Urgent Care For a Pre-Service Claim Involving Urgent Care, Capital Health Plan will use its best efforts to provide notice of the determination (whether adverse or not) as soon as possible, but not later than 72 hours after receipt of the Pre-Service Claim unless additional information is required for a coverage decision.

  • In the case of an Adverse Decision relating a Claim for Benefits that is not a Claim Involving Urgent Care, the Plan or the Plan’s Designee shall send the written or electronic Notification within 5 working days after the Adverse Decision has been made.

  • In the case of an Adverse Decision by the Plan or the Plan’s Designee concerning a Claim Involving Urgent Care, a description of the expedited review process applicable to such claims.

  • This Notification shall be provided to the Member, the Member’s Representative, or Health Care Provider acting on behalf of the Member, as appropriate, as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a Claim Involving Urgent Care) following the failure.

  • Any request by a Member to extend the course of treatment beyond the period of time or number of treatments that is a Claim Involving Urgent Care shall be decided as soon as possible, taking into account the medical exigencies.


More Definitions of Claim Involving Urgent Care

Claim Involving Urgent Care means any claim for medical care or treatment in which the application of the regular time period to review a denial of a Pre-service Claim could seriously jeopardize a claimant’s life or health or ability to regain maximum function, or, in the opinion of a physician with knowledge of a claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the requested care or treatment.
Sample 1

Related to Claim Involving Urgent Care

  • Urgent Care means treatment for a condition that is not a threat to life or limb but does require prompt medical attention. Also, the severity of an urgent condition does not necessitate a trip to the hospital emergency room. An Urgent Care facility is a freestanding facility that is not a physician’s office and which provides Urgent Care.

  • Title IV-E Foster Care means a federal program authorized under §§ 472 and 473 of the Social

  • Urgent Care Claim means a claim for medical care or treatment where making a non-urgent care decision: (a) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, as determined by an individual acting on behalf of the plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; or (b) in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care.

  • Urgent care request means a claim relating to an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, or any Pre-Service Claim or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination:

  • Long-term inpatient care means inpatient services for

  • Investigative consumer report means a consumer report or portion thereof in which information about a natural person's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with the person's neighbors, friends, associates, acquaintances, or others who may have knowledge concerning such items of information.

  • In Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

  • Routine patient care costs means Covered Medical Expenses which are typically provided absent a clinical trial and not otherwise excluded under the Policy. Routine patient care costs do not include:

  • Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

  • Criminal background check means a state criminal background check and a national criminal history check through the Federal Bureau of Investigation.

  • Claims processing services means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include:

  • Claims Process means the process for Settlement Class Members’ submission of Claims, as described in Section III.

  • Direct care means direct, hands-on personal care and supervi- sion to group care children and youth.

  • Skilled Nursing Care means that level of care which:

  • Adverse reaction means an unexpected outcome that threatens the health or safety of a patient as a result of a medical service, nursing service, or health-related service provided to the patient.

  • Unassigned medication for respiratory distress means albuterol, levalbuterol, or another medication designated by the executive commission of the Health and Human Services Commission for treatment of respiratory distress, prescribed by an authorized health-care provider in the name of the district with a non-patient-specific standing delegation order for the administration of a medication for respiratory distress, and issued by an authorized health-care provider.

  • Criminal street gang-related offense means any felony or

  • Domestic content procurement preference ’ means all iron and steel used in the project are produced in the United States; the manufactured products used in the project are produced in the United States; or the construction materials used in the project are produced in the United States.

  • Clinical nurse specialist means a registered nurse with relevant post-basic qualifications and 12 months’ experience working in the clinical area of his/her specified post-basic qualification, or a minimum of four years’ post-basic registration experience, including three years’ experience in the relevant specialist field and who satisfies the local criteria.

  • Pharmaceutical care means the provision of drug therapy and

  • Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Hospice Care means a coordinated program of active professional

  • Pharmacy care means medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.

  • Qualified Medical Child Support Order means a Medical Child Support Order which creates (including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits to which a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined by the Plan Administrator to meet the qualification requirements as outlined under “Procedures” of this provision.

  • Direct Patient Care means the provision of health care services provided directly to individuals being treated for or suspected of having physical or mental illnesses. Direct patient care includes both, face-to-face and telehealth-based preventative care and first-line supervision.

  • Non-Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.