Reso 2010-1529 - Laserfiche WebLink

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I I') ) 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 XVI. o 16.05 Post-Service Claims. 16.05.01 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 16.06 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 determines 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 information, 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 information within the 45-day period, the Claim shall be denied. 16.05.02 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 Clairnant, in accordance with Section 16.08, of AvMed's determination on . review within a reasonable period oftime. Such notification shall be provided not later than 60 days after AvMed receives the Clairnant's request for review of the Adverse Benefit Determination. You rnay submit an appeal to: ) AvMed Mernber 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 16.05.03 If you are not satisfied with AvMed's final decision, you rnay 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 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 42 A V-GlOO-2009 MP-5319 (10/09)