What responsibility does the plan have for determining whether any specific claim involves urgent care and must therefore be decided on an expedited basis?
A plan has a duty to make this determination on the basis of the information provided by, or on behalf of, the claimant. A claim involving urgent care is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the claimants ability to regain maximum function, or — in the opinion of a physician with knowledge of the claimants 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. In determining whether a claim involves urgent care, the plan must apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the claimants medical condition determines that a claim involves urgent care, the claim must be treated as an urgent care claim. See 2560.503-1(m)(1).
A plan has a duty to make this determination on the basis of the information provided by, or on behalf of, the claimant. A claim involving urgent care is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the claimant s ability to regain maximum function, or — 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. In determining whether a claim involves urgent care, the plan must apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the claimant s medical condition determines that a claim involves urgent care, the claim must be treated as an urgent care claim. See § 2560.503-1(m)(
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