Emergency and Urgently Needed Care. No prior authorization required, following the reasonable person standard to determine that the presenting complaint might be an emergency.
Emergency and Urgently Needed Care. Health Net uses a prudent layperson standard to determine whether the criteria for Emergency Care have been met. Health Net applies the prudent layperson standard to evaluate the necessity of medical services which a Member accesses in connection with a condition that the Member perceives to be an emergency situation. Please refer to "Emergency Care" in the "Definitions" section to see how the prudent layperson standard applies to the definition of "Emergency Care." Please refer to the following information for a description of how to access your emergency benefits. Additional information is also located in the "Schedule of Benefits and Copayments" section. WHAT TO DO WHEN YOU NEED MEDICAL CARE IMMEDIATELY In serious emergency situations: Call “911” or go to the nearest Hospital. If your situation is not so severe: Call your Primary Care Physician or Physician Group (medi- cal) or the Behavioral Health Administrator (Mental Disorders and Chemical Dependency) or, if you cannot call them or you need medical care right away, go to the nearest medical center or Hospital. If you are unsure of whether an emergency medical condition exists, you may call your Physician Group or Primary Care Physician for assistance. Your Physician Group is available 24 hours a day, seven days a week, to respond to your phone calls regarding medical care that you believe is needed immediately. They will evaluate your situation and give you directions about where to go for the care you need. Except in an emergency or other urgent medical circumstances, the covered services of this Plan must be performed by your Physician Group or authorized by them to be performed by others. You may use other provid- ers outside your Physician Group only when you are referred to them by your Physician Group. If you are not sure whether you have an emergency or require urgent care please contact Health Net at the number shown on your Health Net I.D. card. As a Health Net Member, you have access to triage or screening services, 24 hours per day, 7 days per week. Urgently Needed Care within a 30-mile radius of your Physician Group and all Non-Emergency Care must be performed by your Physician Group or authorized by them in order to be covered. These services, if performed by others outside your Physician Group, will not be covered unless they are authorized by your Physician Group. Urgently Needed Care outside a 30-mile radius of your Physician Group and all Emergency Care (includ- ing care outside of ...
