2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 72
Procedures for all Claims
The Plan's claim procedures are modeled on the Department of Labor's claims procedures regulations.
To receive benefits under the Plan, the claimant (i.e. you and your covered Dependents) must follow the procedures
outlined in this section. There are 4 different types of claims: (1) Urgent Care Claims; (2) Concurrent Care Claims; (3)
Pre-Service Claims; and (4) Post-Service Claims. The procedures for each type of claim are more fully described
below:
(1)
Urgent Care Claims. If your claim is considered an urgent care claim, the Plan Administrator will notify you
of the Plan's benefit determination (whether adverse or not) as soon as possible, taking into account the
medical exigencies, but not later than 72 hours after the Plan receives the claim, unless you fail to provide
sufficient information to determine whether or to what extent, benefits are covered or payable under the Plan.
If you fail to provide sufficient information for the Plan to decide your claim, the Plan Administrator will notify
you as soon as possible, but not later than 24 hours after the Plan receives the claim, of the specific information
necessary to complete the claim. The notification may be oral unless written notification is requested by you.
You will be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48
hours, to provide the specified information. The Plan Administrator will notify you of the Plan's determination
as soon as possible, but in no case later than 48 hours after the earlier of (1) the Plan's receipt of the specified
additional information or (2) the end of the period afforded the claimant to provide the specified additional
information.
A claim for benefits is considered an urgent care claim if the application of the time periods for making nonurgent care determinations could seriously jeopardize your life or health or your ability to regain maximum
function or, in the opinion of a Physician with knowledge of your medical condition, would subject you to severe
pain that could not be adequately managed without the care or treatment which is the subject of the claim.
(2)
Concurrent Care Claims. If the Plan has approved an ongoing course of health care treatment to be provided
over a period of time or number of treatments, any reduction or termination by the Plan of the previously
approved course of treatment (other than by Plan amendment or termination) before the approved time period
or number of treatments constitutes an Adverse Determination. In such a case, the Plan Administrator will
notify you of the Adverse Determination at a time sufficiently in advance of the reduction or termination to
allow you, the claimant, to appeal and obtain a determination on review of that Adverse Determination before
reduction or termination of the benefit.
Any request by you to extend a previously approved course of urgent care treatment beyond the approved
period of time or number of treatments shall be decided as soon as possible, taking into account the medical
exigencies. The Plan Administrator will notify you of the benefit determination, whether adverse or not, within
24 hours after the Plan receives the claim, provided that any such claim is made to the Plan at least 24 hours
prior to the expiration of the prescribed period of time or number of treatments.
(3)
Pre-Service Claims. For a pre-service claim, the Plan Administrator will notify you of the Plan's benefit
determination (whether adverse or not) within a reasonable period of time appropriate to the medical
circumstances, but not later than 15 days after the Plan receives the claim. If, due to matters beyond the
control of the Plan, the Plan Administrator needs additional time to process a claim, the Plan Administrator
may extend the time to notify you of the Plan's benefit determination for up to 15 days, provided that the Plan
Administrator notifies you within 15 days after the Plan receives the claim, of those special circumstances and
of when the Plan Administrator expects to make its decision. However, if such an extension is necessary due
to your failure to submit the information necessary to decide the claim, the notice of extension must specifically
describe the required information and you will be afforded at least 45 days from receipt of the notice within
which to provide the specified information.
A claim for benefits is considered a pre-service claim if the claim requires approval, in part or in whole, in
advance of obtaining the health care in question.
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