Urgent Care Appeal definition

Urgent Care Appeal means an appeal for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations (i) could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or (ii) in the opinion of the treating health care professional with knowledge of the covered person’s medical condition, would subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal. an urgent care appeal shall not be available for any post-service claim or retrospective adverse determination.
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Examples of Urgent Care Appeal in a sentence

  • An Urgent Care Appeal is also an Appeal involving care that the treating physician deems urgent in nature, or the treating physician determines that a delay in care would subject the Participant to severe pain that could not be adequately managed without the care or treatment that is being requested.

  • An Appeal that must be reviewed under the expedited Urgent Care Appeal process because the application of non-Urgent Care Appeal timeframes could seriously jeopardize the life or health of the Participant or the Participant’s ability to regain maximum function.

  • A Member or a Member’s health care Provider may request an Urgent Care Appeal either orally or in writing.

  • An Urgent Care Appeal is a request to change an Adverse Benefit Determination for Urgent Care for Covered Services.

  • An Urgent Care Appeal will be reviewed by a PPO Medical Director who did not previously participate in any prior decision relating to the appeal and shall not be a subordinate of the person(s) who made the initial Adverse Benefit Determination.

  • The Claimant shall be responsible to provide information to Geisinger in an expedited manner to allow Geisinger to conform to the Urgent Care Appeal requirements.

  • The Claimant or the Claimant’s health care provider requesting the Urgent Care Appeal may contact Geisinger by telephone, fax or other methods that will expedite receipt of the information by Geisinger.

  • Geisinger shall perform an Urgent Care Appeal Review and render a decision within seventy two (72) hours of receipt of the Claimant’s request.

  • The Urgent Care Appeal review shall include the written input and/or presence of a licensed physician or approved licensed pharmacist in the same or similar specialty that typically manages or consults on the health care service, condition, performs the procedure, or provides the treatment and who was not previously involved in the matter under review.

  • A Claimant or a Claimant’s health care provider may request an Urgent Care Appeal either orally or in writing.

Related to Urgent Care Appeal

  • 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:

  • 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.

  • URGENT CARE CENTER means a healthcare center either affiliated with a hospital or other institution or independently owned and operated. These centers may also be referred to as walk-in centers.

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

  • Managed care plan means a health benefit plan that either requires a covered person to use, or

  • PREVENTIVE CARE SERVICES means covered healthcare services performed to prevent the occurrence of disease as defined by the Affordable Care Act (ACA). See Preventive Care and Early Detection Services in Section 3. PRIMARY CARE PROVIDER (PCP) means, for the purpose of this plan, professional providers that are family practitioners, internists, and pediatricians. For the purpose of this plan, gynecologists, obstetricians, nurse practitioners, and physician assistants may be credentialed as PCPs. To find a PCP or check that your provider is a PCP, please use the “Find a Doctor” tool on our website or call Customer Service.

  • Nursing Care Plan means a plan of care developed by a nurse that describes the medical, nursing, psychosocial, and other needs of a child and how those needs shall be met. The Nursing Care Plan includes which tasks shall be taught, assigned, or delegated to the qualified provider or family.

  • 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:

  • Nursing diagnosis means a judgment made by a registered nurse, following a nursing assessment of individuals and groups about actual or potential responses to health problems, which forms the basis for determining effective nursing interventions.

  • Primary care physician means a physician qualified to be an attending physician according to ORS 656.005(12)(b)(A) and who is a general practitioner, family practitioner, or internal medicine practitioner.

  • Dependent care assistance program or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

  • Medicare Levy Surcharge means an extra charge payable by high income earners beyond the standard Medicare Levy if they do not have qualifying private hospital insurance coverage. This charge is assessed as part of an individual or family’s annual tax return.

  • Emergency medical care provider means an individual who has been trained to provide emergency and nonemergency medical care at the first responder, EMT-basic, EMT-intermediate, EMT-paramedic, paramedic specialist or other certification levels recognized by the department before 1984 and who has been issued a certificate by the department.

  • Managed Care Plans means all health maintenance organizations, preferred provider organizations, individual practice associations, competitive medical plans and similar arrangements.

  • Child Care Program means a person or business that offers child care.

  • 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.

  • Managed Care Program means the process that determines Medical Necessity and directs care to the most appropriate setting to provide quality care in a cost-effective manner, including Prior Authorization of certain services.

  • psychiatric emergency medical condition means a Mental Disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following:

  • Vocational rehabilitation services means the unit of vocational rehabilitation established in IC 12-12-1-2(2) as a unit of the rehabilitation services bureau in DDRS.

  • HMO a health maintenance organization doing business as such (or required to qualify or to be licensed as such) under HMO Regulations.

  • Medical care facility as used in this title, means any institution, place, building or agency, whether

  • Health care decision means any decision regarding the health care of the prospective donor.

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

  • child care element of working tax credit means the element of working tax credit prescribed under section 12 of the Tax Credits Act 2002 (child care element).