Reso 2010-1529 - Laserfiche WebLink

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) the requirements of Section 15.06, shall be provided to the Claimant no later than three days after the oral notification. ') 15.04.03 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 15.08, of AvMed's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after AvMed receives the Claimant's request for review of an 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 15.04.04 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Financial Services (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 the AHCA or DFS at any time to inform them of an ul11esolved grievance. -j 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. If you 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 ) 15.05 Concurrent Care Claims 15.05.01 Any reduction or termination by AvMed of Concurrent Care (other than by Plan amendment or termination) before the end of an approved period of time or number of treatments, shall constitute an Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 15.06, of the Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow the Claimant to appeal and obtain a detennination on review of the Adverse Benefit Determination before the benefit is reduced or terminated. 15.05.02 Any request by a Claimant to extend ihe course of treatment beyond the period of time or number of treatments that relates to an Urgent Care Claim shall be decided as soon as possible, taking into account the medical exigencies, and AvMed shall notify the Claimant of the benefit determination, whether adverse or not, within 24 hours after AvMed receives the Claim, provided that any such Claim is made to AvMed at least 24 hours before the expiration of the prescribed period of time or number of treatments. Notification and appeal of any Adverse Benefit Determination concerning a request to extend the course of treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with the remainder of Part XV. 45 A V-CHOICE-2009 Mp-5320 (10/09)