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. No prior authorization required, following the reasonable person
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 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. It is critical that you contact your Physician Group as soon as you can after receiving emergency services from others outside your Physician Group. Your Physician Group will evaluate your circumstances and make all necessary arrangements to assume responsibility for your continuing care. They will also advise you about how to obtain reimbursement for charges you may have paid. Always present your Health Net ID Card to the health care provider regardless of where you are. It will help them understand the type of coverage you have and they may be able to assist you in contacting your Physician Group.
