Emergency Room. This plan covers services you get in a hospital emergency room for an emergency medical condition. An emergency medical condition includes things such as heart attack, stroke, serious burn, chest pain, severe pain or bleeding that does not stop. You should call 911 or the emergency number for your local area. You can go to the nearest hospital emergency room that can take care of you. If it is possible, call your physician first and follow their instructions. You do not need prior authorization for emergency room services. However, you must let us know if you are admitted to the hospital from the emergency room as soon as reasonably possible. See Prior Authorization for details. Covered services include the following: Professional and facility charges for the emergency room and the emergency room doctor Services used for emergency medical conditions, including screenings, exams and patient observation for stabilizing a medical condition Outpatient tests billed by the emergency room and that you get with other emergency room services Benefits are covered at the in-network cost share up to the allowed amount from any hospital emergency room. You pay any amounts over the allowed amount when you get services from non-contracted providers even if the hospital emergency room is in an in-network hospital. If you pay out of pocket for prescription medications associated with an emergency medical need, submit a claim to us for reimbursement. See Sending Us a Claim for instructions. This benefit does not cover the inappropriate (non-emergency) use of an emergency room. This means services that could be delayed until you can be seen in your doctor's office. This could be for things like minor illnesses such as a cold, check-ups, follow-up visits and prescription drug requests. Emergency Ambulance Services This plan covers emergency ambulance services to the nearest facility that can treat your condition. The medical care you get during the trip is also covered. These services are covered only when any other type of transport would put your health or safety at risk. Covered services also include transport from one medical facility to another as needed for your condition. This plan covers ambulance services from licensed providers only and only for the member who needs transport. Payment for covered services will be paid to the ambulance provider or to both the ambulance provider and you. Prior authorization is required for non-emergency ambulance services. See P...
Emergency Room. The section of a hos- pital equipped to furnish emergency care to prevent the death or serious impairment of the covered person.
Emergency Room. Full coverage for first visit for services related to traumatic accident, poisoning or specifically noted medical emergency condition within 24 hours in a general hospital. All diagnostic machine tests are covered. Surgical Care Full coverage for any medically necessary surgical procedure, including administration of anesthesia by a physician of your choice. Diagnostic Laboratory & X-Ray Full coverage.
Emergency Room. For the outpatient hospital emergency room service category and the corresponding physician emergency room visits category, we reviewed the following: (1) CY 2016 managed care utilization levels for each MCP and (2) the resulting classification of claims using the NYU Center for Health and Public Service Research (CHPSR) Emergency Department Algorithm. The NYU CHPSR tool classifies emergency room utilization into four (4) primary categories as well as categories that are excluded from the grouping. The four categories include: Non-emergency, Emergency/Primary Care Treatable, Emergency–Preventable/Avoidable, and Emergency–Not Preventable/Avoidable. Subsequent to the review of the experience into these defined categories, we developed specific adjustments for the first three categories to reflect the target utilization levels for the managed care plans. The following illustrates the adjustments by emergency room classification: Non-emergency – 20% Reduction Emergency/Primary Care Treatable – 10% Reduction Emergency – Preventable/Avoidable – 5% Reduction When applying the adjustments listed above, reductions were taken from level 1 emergency room claims first, followed by level 2 and level 3 claims if applicable. No adjustments were made to level 4 or level 5 emergency room claims. In coordination with determination of the managed care adjustments for hospital outpatient emergency room services, we assumed that most emergency room visits reduced would be replaced with an office visit. The utilization of professional office visits and consults was increased proportionately. Inpatient Hospital We applied managed care adjustments to base year utilization to reflect higher levels of care management relative to the CY 2016 experience period. We identified potentially avoidable admissions using the AHRQ prevention quality indicators (PQI). We also analyzed the frequency of re-admissions for the same DRG. Inpatient hospital managed care adjustments were developed by applying assumed reductions to potentially avoidable inpatient admissions and same-DRG readmissions. This analysis was completed at the population and regional level. Our analysis was completed at the regional level by first reducing readmissions within 30 days, and then reducing non- readmissions for select PQIs. Inpatient hospital managed care adjustments were developed by applying a 10% reduction to same-DRG readmissions and a 5% reduction to potentially avoidable inpatient admissions. In comple...
Emergency Room. For admissions through the Emergency Room in which there is: (a) a direct admission to Provider’s intensive care units for the provision of Emergency Services, (b) a direct transfer to Provider’s operating room for the provision of Emergency Services, or (c) an authorization by Health Plan or its agents for the provision of post-stabilization care, Health Plan will not retrospectively deny payment for the day of admission. For all other services, including those admissions through the Emergency Room that resulted in more than a one (1) day admission, Health Plan reserves the right to retrospectively review such claims to determine if such services were Medically Necessary and may deny payment for any such services which do not constitute Covered Services. Notwithstanding the foregoing, Provider is not required to obtain authorization from Health Plan prior to the provision of Emergency Services and care necessary to stabilize a Member’s emergency medical condition. Health Plan will not retrospectively deny payment for any services rendered by Provider in good faith pursuant to the prior authorization of Health Plan.
Emergency Room. As of January 1, 2014: $100 co-pay. As of January 1, 2018: $150 co-pay, waived if admitted.
Emergency Room. Not a Covered Benefit
Emergency Room. If there is a disagreement between St. Vincent’s Occupational Health Services Center and the employee’s personal physician regarding the medical restrictions, a third opinion by a mutually agreed upon physician shall prevail.
Emergency Room. When services are due to accidental injury to sound natural teeth. $100 - After deductible The level of coverage is the same as network provider.
Emergency Room. When services are due to accidental injury to sound natural teeth. $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $30 20% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
