Reso 2010-1529 - Laserfiche WebLink

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) 16.03.02 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 the requirements of Section 16.06, shall be provided to the Claimant no later than 3 days after the oral notification. 16.03.03 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 16.08, ofAvMed'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 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 1 16.03.04 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 fmal 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 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. If you need further assistance, you may contact: Subscriber Assistance Program (SAP) Florida Department of Financial Services Agency for Health Care Administration 200 East Gaines Street HMO Section Tallahassee, Florida 32399 2727 Mahan Drive, Mail Stop 26 Telephone 1-800-342-2762 Tallahassee, Florida 32308 Telephone 1-888-419-3456, or 850-921-5458 ) 16.04 Concurrent Care Claims 16.04.01 Any reduction or termination by AvMed ofConcUITent 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 16.06, of the Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow the Clairnant to appeal and obtain a determination on review of the Adverse Benefit Determination before the benefit is reduced or terminated. 16.04.02 Any request by a Claimant to extend the 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 rnedical exigencies, and AvMed shall notify the Claimant of the benefit determination, whether adverse or not, within 24 hours after Av Med 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 41 A V-G 100-2009 MP-5319 (10/09)