There are different categories of claims that can be made under the Plan.
Claim Type | Description | Decision Timeframe |
|---|---|---|
Pre-service Claim | Requires advance certification of medical necessity before obtaining care. | Within 15 days after receiving request |
Urgent Care Claim | A pre-service claim for urgent care where delay could jeopardize health or cause severe pain. | As soon as possible, but no later than 72 hours |
Post-service Claim | Applied after care is received and does not require pre-approval. | Within 30 days after receiving claim |
Incorrect Pre-service | Notified within 5 days if incorrectly filed. | N/A |
Incorrect Urgent Care | Notified within 24 hours if incorrectly filed. | N/A |
Urgent care claim is incomplete | Notified as soon as possible, no later than 24 hours. Description provided; complete claim within specified time. | Decided as soon as possible, no later than 48 hours after receiving information or specified time expires. |
Pre-service or post-service claim is incomplete | Extension notice includes missing info details with timeframe (min. 45 days) for submission. | Decision within the extended period if provided, or may proceed without info if not submitted. |
Pre-service Claim
A claim is a pre-service claim if it requires certification of medical necessity in advance of obtaining the medical care.
Urgent Care Claim
An urgent care claim is a special type of pre-service claim. A claim involving urgent care is any pre-service claim for medical care or treatment when the time periods that otherwise apply to pre-service claims could seriously jeopardize the participant's life or health or ability to regain maximum function or would, in the opinion of a provider with knowledge of the participant's medical condition, subject the participant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Post-service Claim
A post-service claim is any claim for a benefit under the Plan that is not a pre-service claim or an urgent care claim.
The Plan will decide an initial pre-service claim within a reasonable time appropriate to the medical circumstances, but no later than 15 days after receipt of the certification request. The Plan will decide an initial urgent care claim as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the certification request. The Plan will decide an initial post-service claim within a reasonable time but no later than 30 days after receipt of the claim.
Incorrect Pre-service
Despite the specified timeframes, nothing prevents the participant from voluntarily agreeing to extend the above timeframes. In addition, if the Plan is not able to decide a pre-service or post-service claim within the above timeframes, due to matters beyond its control, one 15-day extension of the applicable timeframe is permitted, provided that the participant is notified in writing before the expiration of the initial timeframe applicable to the claim. The extension notice will include a description of the matters beyond the Plan's control that justify the extension and the date by which a decision is expected. No extension is permitted for urgent care claims.
Incorrect Urgent Care
In the case of an incorrectly filed pre-service claim, the participant will be notified as soon as possible but no later than five days following receipt by the Plan of the incorrectly filed claim; and in the case of an incorrectly filed urgent care claim, the participant will be notified as soon as possible but no later than 24 hours following receipt by the Plan of the incorrectly filed claim. The notice will explain that the request is not a claim and describe the proper procedures for filing a claim. The notice may be oral unless written notice is specifically requested by the participant.
Incomplete Urgent Care Claim
If an urgent care claim is incomplete, the Plan will notify the participant as soon as possible, but no later than 24 hours following receipt of the incomplete claim. The notification may be made orally to the participant, unless the participant requests written notice, and it will describe the information necessary to complete the claim and will specify a reasonable time, no less than 48 hours, within which the claim must be completed. The Plan will decide the claim as soon as possible but not later than 48 hours after the earlier of receipt of the specified information; or the end of the period of time provided to submit the specified information.
Incomplete Pre-Service or Post-Service Claim
If a pre-service or post-service claim is incomplete, the Plan may deny the claim or may take an extension of time, as described above. If the Plan takes an extension of time, the extension notice will include a description of the missing information and will specify a timeframe, no less than 45 days, in which the necessary information must be provided. The timeframe for deciding the claim will be suspended from the date the extension notice is received by the participant until the date the missing necessary information is provided to the Plan. If the requested information is provided, the Plan will decide the claim within the extended period specified in the extension notice. If the requested information is not provided within the time specified, the claim may be decided without that information.