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.

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