PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

Eligibility Determinations
Determinations of eligibility to participate in
the Plan will be made by the Plan Administrator
rather than the PPO/DRP administrator, but will
otherwise generally follow the same process as
for claims decisions that is outlined in this booklet
(except that the external review process does not
apply to eligibility determinations). If you have
questions about your, your spouse’s (or domestic
partner’s or civil union partner’s) and/or your
child’s eligibility, you should contact Advocate
Benefits Service Center at 1.800.775.4784. If you
would like to request a formal determination
of your (or your dependent’s) eligibility
to participate in the Plan or believe that a
determination of your (or your dependent’s)
eligibility to participate in the Plan was incorrect,
please contact:
Plan Administrator (Attn: Eligibility
Determinations)
Advocate Health Care Network
2025 Windsor Drive
Oak Brook, Illinois 60523
How do I appeal a behavior health claim?
The pre-certification process for inpatient
behavioral illness follows the policies of
the behavioral health administrator. For
all appeals for behavioral health, contact
the behavioral health administrator at
the number shown on your coverage ID
card. For more information on the precertification
process for behavioral health
conditions, see Behavioral Health Care,
page 20.
Claims Decisions
After submission of a claim by you, your
beneficiary or your authorized representative
acting on behalf of you (each a “claimant”), the
applicable PPO/DRP administrator will notify the
claimant of the PPO/DRP administrator’s decision
in writing or by acceptable electronic means, in a
culturally and linguistically appropriate manner,
and within a reasonable time, as follows:
32
Pre-Service Claims
The PPO/DRP administrator will notify the
claimant of a favorable or adverse determination
of a claim for medical care for which the Plan
requires advance approval (including precertification
or utilization review) within a
reasonable time appropriate to the medical
circumstances, but no later than 15 days after
receipt of the pre-service claim.
However, this period may be extended by an
additional 15 days if the PPO/DRP administrator
determines that an extension is necessary due to
matters beyond the control of the administrator.
The PPO/DRP administrator will notify the
claimant of the extension before the end of the
initial 15-day period, the reason(s) the extension
is necessary, and the date by which the PPO/DRP
administrator expects to make a decision.
If the reason for the extension is because
the claimant failed to submit the information
necessary to decide the claim, the notice of
extension will describe the required information
and the claimant will have at least 45 days from
the date of the notice to provide the specified
information. If the claimant’s pre-service claim
does not follow the procedures for filing a preservice
claim, the claimant will receive notice
from the PPO/DRP administrator within 5 days
following the failure.
Urgent Care Claims
The PPO/DRP administrator will determine
whether a claim is an urgent care claim, with
deference to the determination of the attending
provider. The PPO/DRP administrator may require
the claimant to clarify the medical urgency and
circumstances that support the urgent care claim
for expedited decision-making.
The PPO/DRP administrator will notify the
claimant of a favorable or adverse determination
as soon as possible (taking into account the
medical urgency particular to the participant’s
situation) but not later than 72 hours after receipt
of the urgent care claim.