Urgent Care Claim

Circumstances for filing claim

One of the following conditions must be met:

·        Waiting threatens life or health of patient or waiting jeopardizes ability to regain maximum function;

·        Physician says failure to provide care will cause patient to suffer severe pain;

·        Treating physician says urgent care is needed; or

·        Claimant or other individual seeks urgent care, based on prudent layperson standard.

Who may file a claim

Member, authorized representative, or treating physician

How to file claim

Follow instructions in the plan handbook very carefully and completely.

Time limit for plan to respond

72 hours, sooner in case of medical exigency.

Time limit for plan to request for additional information

No later than 24 hours after receipt of the claim, sooner in case of medical exigency.

Time limit for claimant to provide information

Not less than 48 hours after request from plan

Time limit for plan’s response to completed claim

48 hours: 1) after the receipt of additional information, 2) after claimant was supposed to have applied information, whichever comes first.

How plan must notify claimant of denial

Orally within 72 hours; written or electronic notice not later than 3 days after oral notification 

What plan must provide if claim is denied, whether wholly or partially

·        Specific reason for denial

·        Reference to specific plan provision as basis for decision

·        Description of and explanation of additional material or information to complete claim

·        Description of the plan’s review procedures and time limits for appealing claim denial

·        Statement of claimant’s right to bring civil action under 502(a) after completing expedited review procedures

Claimant may request and receive at no charge

·        Copy of any internal rule, guideline, protocol, or similar criterion used in making decision and/or

·        Explanation of  the scientific or clinical judgment for the determination if decision is based on medical necessity or experimental exclusion

Time limit for appealing a denial

Within 180 days of receipt of denial

How claimant may submit appeal

Orally or in writing

What claimant may submit for an appeal

Written information relating to the claim

Plan obligation in considering an appeal

·        Provide, free of charge of charge, access to and copies of all information relevant to the claim

·        Take into account all information submitted by the claimant, even if the information was not included in the original claim.   

·        Have the review conducted by someone other than the original decisionmaker who is not a subordinate of that decisionmaker

·        Ensure that the initial denial will not be given undue weight in the reconsideration

·        Identify experts who provided advice, regardless of whether it was taken.

·        In appeals based in whole or in part on a medical judgment, including possible experimental treatment, assure that the reviewer is a health care professional with appropriate training and experience.

Time limits and notification mechanism for response to appeal

No later than 72 hours after appeal.  Plans must transmit all necessary information by phone, fax, or similarly expeditious method.

What plans must provide if appeal is denied

·        Specific reason for the denial

·        Reference to the relevant plan provision

·        Statement that the claimant can receive free of charge all relevant information

·        Description of any voluntary appeal procedures the  plan offer

·        Statement of the member’s right to bring a civil action

·        Notification that voluntary alternative dispute resolution options may be available and that more information is available from the U.S. Department of Labor or the state agency that regulates insurance.

Claimant may request and receive at no charge

·        Copy of any internal rule, guideline, protocol, or similar criterion considered in making decision and/or

·        Explanation of the scientific or clinical judgment if decision is based on medical necessity or experimental treatment