Reso 2010-1529 - Laserfiche WebLink

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) date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional infonnation. If the Claimant fails to supply the requested information within the 45-day period, the Claim shall be denied. 15.02.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Pre- Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 15.08, of its determination on review within a reasonable period of time. Such notification shall be provided not later than 30 days after AvMed receives the Claimant's request for review of the Adverse Benefit Determination. You may submit an appeal to: AvMed Member Services - North P.O. Box 823 Gainesville, Florida 32602-0823 Telephone: 1-800-882-8633 Fax: (352) 337-8612 ) AvMed Member Services - South P.O. Box 569008 Miami, Florida 33156-9906 Telephone: 1-800-882-8633 Fax: (305) 671-4736 - ) 15.02.03 If you are not satisfied with AvMed's final decision, you may contact AHCA or DFS in writing within 365 days of receipt of the final decision letter. If you appeal AvMed's decision, your grievance will be reviewed by the Subscriber Assistance Program. You also have the right to contact AHCA or DFS at any time to infornl them of an ul11esolved grievance. a) The Subscriber Assistance Program will not hear a grievance if you have not completed the entire AvMed grievance process nor if you have instituted an action pending in State or Federal court. Uyau need further assistance, you may contact: Subscriber Assistance Program (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1-888-419-3456, or 850-921-5458 Florida Department of Financial Services 200 East Gaines Street Tallahassee, Florida 32399 Telephone 1-800-342-2762 ) 15.03 Post-Service Claims. 15.03.01 Initial Claim. A Post-Service Claim shall be deemed to be filed on the date received by AvMed. AvMed shall notify the Claimant, in accordance with Section 15.06 of AvMed's Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after AvMed receives the Post-Service Claim. AvMed may extend this period one time for up to 15 days, provided that AvMed detennines that such an extension is necessary due to matters beyond AvMed's control and notifies the Claimant, before the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which AvMed expects to render a decision. If such an extension is necessary because the Claimant failed to submit the information necessary to decide the Post-Service Claim, the notice of extension shall specifically describe the required infonnation, and the Claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. AvMed's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information. If the Claimant fails to supply the requested infonnation within the 45-day period, the Claim shall be denied. 43 A V-CHOICE-2009 MP-5320 (10/09)