How are urgent claims affected by DOL regulations?

Health plans must use a "prudent layperson" standard to determine whether a claim is for urgent care. However, if a physician with knowledge of the member's medical condition determines the claims involves urgent care, the health plan must treat it as such.

If an urgent claim is incomplete or not properly filed, the member must be notified within 24 hours and will have 48 hours to provide the necessary information.

The member is entitled to a notice of the initial determination (whether adverse or not) as soon as possible, taking into account the medical urgency of the case, but no later than 72 hours after receiving the claim. The notice may be provided orally as long as the plan provides a written notice within three day after the oral notice is provided.

Was this content helpful?

Rate it

Submit >

©1996-2014 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. We provide health insurance in Michigan.

State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

Site Map  |  Feedback  |  Important Legal and Privacy Information

Explanation of Level A Conformance
Better Business Bureau Online Seal of Reliability