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Urgent Care Claims


A claim involving "urgent care" is any claim for medical care or treatment when a normal time period may:

 

  •  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 be managed without the treatment that is the subject of the claim. In determining whether a claim involves urgent care, the plan must apply the judgment of a prudent layperson that possesses an average knowledge of health and medicine. However, if a physician with knowledge of the claimant's medical condition determines that a claim involves urgent care, the claim must be treated as an urgent care claim.

 

  • Urgent care claims must be decided as soon as possible, taking into account the medical emergency, but not later than 72 hours after receipt and pre-service claims must be decided within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt.

 

  • The plan must tell the claimant within 24 hours if more information is needed; they will have no less than 48 hours to respond. Then the plan must decide the claim within 48 hours after the missing information is supplied or the time to supply it has elapsed. The plan cannot extend the time to make the initial decision without the claimant's consent.

 


If, on the other hand, the plan believes based on its own review of the claim that expedited processing is required, the claim must be processed on an expedited basis without regard to the claimant's failure to provide information relating to whether expedited processing is necessary.

 

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.