Emergency Care. If you need emergency care, call 911 or go to the nearest hospital emergency room. If you are traveling outside our service area and need urgent care, call the Customer Service number provided in the chart above or visit our website and use the “Find A Doctor” feature to find a BlueCard provider.
Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days...
Emergency Care. See Medical Emergency at section 2.98.
Emergency Care. If you need emergency care, call 911 or go to the nearest hospital emergency room.
Emergency Care. Medically Necessary services will be covered whether You get care from an In- Network or Out-of-Network Provider. For information on Your Cost Shares for Emergency Services, please see the SUMMARY OF BENEFITS, HOW YOUR COVERAGE WORKS and the “Ambulance Services” section above. Emergency Services Benefits are available for services and supplies to treat the onset of symptoms for an Emergency, which is defined below. Emergency (Emergency Medical Condition)
Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR 438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by DHHR.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for Medcaid emergency transportation at a rate of at least one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees or their representatives regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency ca...
Emergency Care. Emergency care means treatment due to injury, accident, or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically nor physically possible for the Member to be treated by any Company Participating General Dentist or Participating Specialist. An acute periodontal abscess and an acute periapical abscess which occur under circumstances where it is not possible for the Member to be treated by any Company Participating General Dentist or Participating Specialist are examples where emergency benefits would be applicable.
Emergency Care. If you need emergency care, call 911 or go to the nearest hospital emergency room. If you are traveling outside our service area and need urgent care, call the number provided in the BlueCard Access section above. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. HealthSource RI (HSRI) For questions concerning enrollment through HSRI call 0-000-000-0000 or visit their website at xxx.xxxxxxxxxxxxxx.xxx.
Emergency Care. Covered inpatient or outpatient hospital services for an emergency medical condition which means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child):
Emergency Care. A Member is covered for Emergency Services, provided the service is a Covered Benefit, and HMO's review determines that a Medical Emergency existed at the time medical attention was sought by the Member. The Copayment for an emergency room visit as described on the Schedule of Benefits will not apply either in the event that the Member was referred for such visit by the Member’s PCP for services that should have been rendered in the PCP’s office or if the Member is admitted into the Hospital. The Member will be reimbursed for the cost for Emergency Services rendered by a non- participating Provider located either within or outside the HMO Service Area, for those expenses, less Copayments, which are incurred up to the time the Member is determined by HMO and the attending Physician to be medically able to travel or to be transported to a Participating Provider. In the event that transportation is Medically Necessary, the Member will be reimbursed for the cost as determined by HMO, minus any applicable Copayments. Reimbursement may be subject to payment by the Member of all Copayments which would have been required had similar benefits been provided during office hours and upon prior Referral to a Participating Provider. Medical transportation is covered during a Medical Emergency.
