Non-Urgent Pre-Service Claim
For a properly filed Non-Urgent Pre-Service Claim, you
and/or your doctor will be notified of a decision within
15 days from receipt of the claim unless additional time
is needed. The time for a response may be extended up to
15 days if necessary due to matters beyond the control
of the Claim Administrator responsible for making the
determination. You will be notified of the circumstances
requiring the extension of time and the date by which a
decision is expected to be rendered.
If you improperly file a Non-Urgent Pre-Service Claim,
you will be notified as soon as possible, but not later than
five days after receipt of the claim, of the proper procedures
to be followed in filing a claim. You will only receive
notice of an improperly filed Non-Urgent Pre-Service
Claim if the claim includes the following important
information:
- your name;
- your specific medical condition or symptom; and
- a specific treatment, service or product forwhich approval is requested.
Unless the claim is resubmitted properly, it will not
constitute a claim.
If an extension is needed because the Claim Administrator
responsible for making the determination needs additional
information from you, the extension notice will specify the
information needed. In that case you and/or your doctor
will have 45 days from receipt of the notification to supply
the additional information. During the period in which
you are allowed to supply additional information, the
normal period for making a decision on the claim will be
suspended. The deadline is suspended from the date of the
extension notice either for 45 days or until the date you
respond to the request (whichever is earlier).
The Claim Administrator then has 15 days to make a
decision on the Non-Urgent Pre-Service Claim and
notify you of the determination. You have the right to
appeal a denial of your Non-Urgent Pre-Service Claim.
See here.
