SSMC Employee Health Benefit Plan
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Was submitted, considered, or generated in the course of making the benefit determination, without
regard to whether such document, record, or other information was relied upon in making the benefit
determination.
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Demonstrates compliance with the administrative processes and safeguards required under federal law.
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Constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment
option or benefit for the Claimant's diagnosis, without regard to whether such advice or statement was
relied upon in making the benefit determination.
URGENT CARE CLAIM/CLAIM INVOLVING URGENT CARE. Any Pre-Service Claim for
medical care or treatment for which application of the time periods for non-urgent care determinations:
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Could seriously jeopardize the life or health of the Claimant or the ability of the Claimant to regain
maximum function; or
Note: Except as provided for Claims that a Physician determines to be urgent care shown below; the
determination whether a "Claim Involving Urgent Care '' is made by an individual, acting on behalf of the Plan
and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.
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In the opinion of a Physician with knowledge of the Claimant's medical condition, would subject the
Claimant to severe pain that cannot be adequately managed without the care or treatment that is the
subject of the Claim.
Note: Any Claim that a Physician with knowledge of the Claimant's medical condition determines is a ``Claim
Involving Urgent Care '' within this meaning shall be treated as an Urgent Care Claim.
2. Plan Notifications.
a. Claimant Failure to Follow Plan Procedures for Filing Pre-Service Claims (Non-urgent or Urgent
Care Pre-Service Claims). The Plan will notify the Claimant when communications from the Claimant
failed to follow the Plan procedures for filing a Pre-Service Claim. Notification of failure may be oral
unless the Claimant or authorized representative requests written Notification. Plan Notification is not
required for general inquiries about the Plan.
b. Communications from Claimant or Authorized Representative. Notification requirement applies
in the case of a failure by the Claimant to follow Plan filing procedures for Pre-Service Claims that:
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Is a written communication (written or oral for urgent pre-service claims) by a Claimant or an
authorized representative of a Claimant that is received by a person or organizational unit
customarily responsible for handling benefit matters; and
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Is a communication that names a specific Claimant; a specific medical condition or symptom; and
a specific treatment, service, or product for which approval is requested.
c. Notification Timelines Pre-Service Claims. Plan Notification of such failure must be provided to
Claimant as soon as possible but not later than:
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24 Hours for Urgent Care Claims
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5 calendar days for Non-Urgent Claims
d. Plan Notification Timelines for Claim Determination (Adverse or not). The Plan will send written
(oral or written for Urgent Care) or electronic Notification for Adverse Benefit Determinations. See
Manner and Content of Notification described later.
1) Calculating Time Periods for Plan Notice of Determination. Time periods start at the time the
Claim is filed in accordance with reasonable requirements of the Plan without regard to whether all
