Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

~ ) 15.03.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Post- Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 15.08, of AvMed's determination on review within a reasonable period of time. Such notification shall be provided not later than 60 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 AvMed Member Services - South P.O. Box 823 P.O. Box 569008 Gainesville, Florida 32602-0823 Miami, Florida 33156-9906 Telephone: 1-800-882-8633 Telephone: 1-800-882-8633 Fax: (352) 337-8612 Fax: (305) 671-4736 15.03.03 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 AI-ICA or DFS at any time to inform them of an unresolved 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: t) ) 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 I ) 15.04 Urgent Care Claims. 15.04.01 Initial Claim. An Urgent Care Claim sh~lI be deemed to be filed on the date received by AvMed. AvMed shall notify the Claimant of AvMed's benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after AvMed. receives, either orally or in writing, the Urgent Care Claim, unless the Claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. If such information is not provided, AvMed shall notify the Claimant as soon as possible, but not later than 24 hours after AvMed receives the Claim, of the specific information necessary to complete the Claim. The Claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. AvMed shall notify the Claimant of the benefit determination as soon as possible, but in no case later than 48 hours after the earlier of: a) AvMed's receipt of the specified infornlation; or b) The end of the period afforded the Claimant to provide the specified additional information. 15.04.02 If the Claimant fails to supply the requested information within the 48-hour period, the Claim shall be denied. AvMed may notify the Claimant of the benefit determination orally or in writing. If the notification is provided orally, a written or electronic notification, meeting 44 A V-CHOlCE-2009 MP-5320 (10/09)