CALIFORNIA - Pacificare Health Systems

notification is received by the Member until
the date on which (1) the Member responds
with the specified information or (2) the end
of the period of time provided to submit the
specified information, whichever is earlier.
b. Urgent Requests. A request for Covered
Services will be treated as an “urgent
request” if making a determination pursuant
to the time frames in Section (a) above (i)
could seriously jeopardize the life or health
of the Member, or (ii) if in the opinion of a
Physician with knowledge of the Member’s
medical condition, would subject the
Member to severe pain that cannot be
adequately managed without the care or
treatment that is the subject of the request.
In the event of an urgent request, PacifiCare
or its Participating Medical Group will notify
the Member of its determination to authorize
or deny as soon as possible, taking into
account the Member’s medical condition,
but not later than 72 hours after receipt of
the urgent request. In the event PacifiCare
or its Participating Medical Group does not
have the information necessary to make a
decision regarding the request, PacifiCare
or its Participating Medical Group will notify
the Member as soon as reasonably possible,
but not later than 24 hours after receipt of
the request and will inform the Member
of the specific information necessary for
PacifiCare or its Participating Medical Group
to make a determination regarding the
request, and the reasonable time frame
(no less than 48 hours) for the Member to
provide the specified information. PacifiCare
or its Participating Medical Group will make
a determination as soon as possible but no
later than 48 hours after the earlier of (1)
the receipt of the requested information, or
(2) the end of the period of time provided to
submit the specified information.
c. Concurrent Care Requests. If the Member
requests an extension of a previously
authorized and currently ongoing course
of treatment, and the request is an “urgent
request,” as defined in Section (b) above,
PacifiCare or its Participating Medical Group
will approve or deny the request as soon as
Overseeing Your Health Care
possible, taking into account the Member’s
medical condition, and will notify the
Member of the decision within 24 hours of
the request, provided the Member made
the request to PacifiCare or its Participating
Medical Group at least 24 hours prior to
the expiration of the previously authorized
course of treatment. If the concurrent
care request is not an “urgent request,” as
defined in Section (b) above, PacifiCare or
its Participating Medical Group will treat
the request as a new request for a Covered
Service under the Health Plan and will follow
the time frame for non-urgent requests, as
discussed in Section (a) above.
d. Post-Service Claim. Members will be
notified of denials (in whole or in part) of an
initial post-service claim within a reasonable
period of time, but not later than 30 days
after receipt of the claim. PacifiCare or its
Participating Medical Group may extend the
initial time frame for up to 15 days due to
circumstances beyond its control. However,
if the extension is necessary due to the
Member’s failure to submit the information
necessary for PacifiCare or its Participating
Medical Group to make a decision regarding
the request, the Member will be notified
of the extension, informed of the specific
information necessary to make a decision,
and provided at least 45 days to provide
the specified information. In addition, the
time period for making the determination is
suspended from the date on which extension
notification is received by the Member until
the date on which (1) the Member responds
with the specified information or (2) the end
of the period of time provided to submit the
specified information, whichever is earlier.
3. Appeal. Members have up to 180 days following
receipt of an adverse determination within
which to appeal the determination. Members
are entitled to a full and fair appeals process.
Members may submit written comments,
documents, records and information in support
of their appeal. PacifiCare will notify the Member
of its decision regarding the appeal no later than:
72 hours for an urgent request
Questions? Call the Customer Service Department at 1-800-624-8822. 121
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PART A