Emergency Care Urgent Care Benefits. 1. A Member is covered for Emergency Services, provided the service is a Covered Benefit, and HMO's medical review determines that the Member’s symptoms were severe, occurred suddenly, and immediate medical attention was sought by Member. Medically necessary Emergency Services shall include psychiatric emergency care and care related to alcohol use and abuse including: • immediate medical evaluation and care; • medical management of intoxicated persons until no longer incapacitated by the effects of alcohol; and or • initiation of other appropriate health services needed for continuity or care. Emergency Services related to drug abuse and addiction shall include treatment for overdose and adverse reactions to psycho-tropic substances such as barbiturates, amphetamines, hallucinogens (including marijuana), tranquilizers and narcotics. 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.
Emergency Care Urgent Care Benefits. 1. A Member is covered for Emergency Services for treatment of a Medical Emergency, provided the service is a Covered Benefit, and HMO's medical review determines that the Member’s symptoms were severe, occurred suddenly, and immediate medical attention was sought by Member. A Medical Emergency is a medical condition manifesting itself by acute symptoms of sufficient severity, including but not limited to, severe pain, or by acute symptoms developing from a chronic medical condition that would lead a prudent layperson, possessing an average knowledge of health and medicine, to reasonably expect the absence of immediate medical attention to result in any of the following: 1) placing the health of a Member or with respect to a pregnant women, the health of the female Member or her unborn child in serious jeopardy 2) serious impairment to bodily functions 3) serious dysfunction to any bodily organ or part. 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 Stabilized and able 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.
Emergency Care Urgent Care Benefits
