Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. This Notice is to advise You that in addition to the processes outlined in COMPLAINT AND APPEAL PROCEDURES section of the Certificate and in the Plan Description and Member Handbook, you have the right to seek and obtain a full and fair review by HMO of any Adverse Benefit Determinations made by HMO in accordance with the benefits and procedures detailed in Your Certificate. The reasons for the determination; A reference to the benefit Plan provisions on which the determination is based, or the contractual, administrative or protocol basis for the determination; A description of additional information which may be necessary to perfect the claim and an explanation of why such material is necessary; Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, diagnosis/treatment codes with their meanings and the standards used are also available; An explanation of HMO’s internal review/appeals and external review processes (and how to initiate a review/appeal or external review) and a statement of Your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal; In certain situations, a statement in non-English language(s) that written notice of claim denials and certain other benefit information may be available (upon request) in such non-English language(s); In certain situations, a statement in non- English language(s) that indicates how to access the language services provided by HMO; The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits; Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request; An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant’s medical circumstances, if the denial was based on medical necessity, experimental treatment or similar exclusion, or a statement that such explanation will be provided free of charge upon request; In the case of a denial of an urgent care clinical claim, a description of the expedited review procedure applicable to such claim. An urgent care clinical claim decision may be provided orally, so long as a written notice is furnished to the claimant within 3 days of oral notification; and Contact information for applicable office of health insurance consumer assistance or ombudsman. Urgent Care Clinical Claim is any pre-service claim that requires preauthorization, as described in this Certificate, for benefits for medical care or treatment with respect to which the application of regular time periods for making health claim decisions 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, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment. Pre-Service Claim is any non-urgent request for benefits or a determination with respect to which the terms of the benefit Plan condition receipt of the benefit on approval of the benefit in advance of obtaining medical care. • Post-Service Claim is notification in a form acceptable to HMO that a service has been rendered or furnished to You. This notification must include full details of the service received, including Your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the diagnosis, the claim charge, and any other information which HMO may request in connection with services rendered to You. If Your claim is incomplete, HMO must notify You within: 24 hours If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 48 hours after receiving notice if the initial claim is complete as soon as possible (taking into account medical exigencies), but no later than: 72 hours after receiving the completed claim (if the initial claim is incomplete), within: 48 hours * You do not need to submit Urgent Care Clinical Claims in writing. You should call HMO at the toll- free number listed on the back of Your identification card as soon as possible to submit an Urgent Care Clinical Claim. If Your claim is filed improperly, HMO must notify You within: 5 days If Your claim is incomplete, HMO must notify You within: 15 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice if the initial claim is complete, within: 15 days* after receiving the completed claim (if the initial claim is incomplete), within: 30 days If You require post- stabilization care after an Emergency within: the time appropriate to the circumstance not to exceed one hour after the time of request * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You, prior to the expiration of the initial 15- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision. If Your claim is incomplete, HMO must notify You within: 30 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice if the initial claim is complete, within: 30 days* after receiving the completed claim (if the initial claim is incomplete), within: 45 days * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You in writing, prior to the expiration of the initial 30- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision.
Appears in 1 contract
Sources: Certificate of Coverage
Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. This Notice is to advise You that in addition to the processes outlined in COMPLAINT AND APPEAL PROCEDURES section of the Certificate and in the Plan Description and Member Handbook, you have the right to seek and obtain a full and fair review by HMO of any Adverse Benefit Determinations made by HMO in accordance with the benefits and procedures detailed in Your Certificate. • The reasons for the determination; • A reference to the benefit Plan provisions on which the determination is based, or the contractual, administrative or protocol basis for the determination; • A description of additional information which may be necessary to perfect the claim and an explanation of why such material is necessary; • Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, diagnosis/treatment codes with their meanings and the standards used are also available; • An explanation of HMO’s internal review/appeals and external review processes (and how to initiate a review/appeal or external review) and a statement of Your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal; • In certain situations, a statement in non-English language(s) that written notice of claim denials and certain other benefit information may be available (upon request) in such non-English language(s); • In certain situations, a statement in non- English language(s) that indicates how to access the language services provided by HMO; • The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits; • Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request; • An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant’s medical circumstances, if the denial was based on medical necessity, experimental treatment or similar exclusion, or a statement that such explanation will be provided free of charge upon request; • In the case of a denial of an urgent care clinical claim, a description of the expedited review procedure applicable to such claim. An urgent care clinical claim decision may be provided orally, so long as a written notice is furnished to the claimant within 3 days of oral notification; and • Contact information for applicable office of health insurance consumer assistance or ombudsman. • Urgent Care Clinical Claim is any pre-service claim that requires preauthorization, as described in this Certificate, for benefits for medical care or treatment with respect to which the application of regular time periods for making health claim decisions 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, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment. • Pre-Service Claim is any non-urgent request for benefits or a determination with respect to which the terms of the benefit Plan condition receipt of the benefit on approval of the benefit in advance of obtaining medical care. • • Post-Service Claim is notification in a form acceptable to HMO that a service has been rendered or furnished to You. This notification must include full details of the service received, including Your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the diagnosis, the claim charge, and any other information which HMO may request in connection with services rendered to You. If Your claim is incomplete, HMO must notify You within: 24 hours If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 48 hours after receiving notice if the initial claim is complete as soon as possible (taking into account medical exigencies), but no later than: 72 hours after receiving the completed claim (if the initial claim is incomplete), within: 48 hours * You do not need to submit Urgent Care Clinical Claims in writing. You should call HMO at the toll- free number listed on the back of Your identification card as soon as possible to submit an Urgent Care Clinical Claim. If Your claim is filed improperly, HMO must notify You within: 5 days If Your claim is incomplete, HMO must notify You within: 15 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice if the initial claim is complete, within: 15 days* after receiving the completed claim (if the initial claim is incomplete), within: 30 days If You require post- stabilization care after an Emergency within: the time appropriate to the circumstance not to exceed one hour after the time of request * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You, prior to the expiration of the initial 15- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision. If Your claim is incomplete, HMO must notify You within: 30 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice if the initial claim is complete, within: 30 days* after receiving the completed claim (if the initial claim is incomplete), within: 45 days * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You in writing, prior to the expiration of the initial 30- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision.
Appears in 1 contract
Sources: Certificate of Coverage