Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Out-of-network Hospital you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours so we can review your Hospital stay. For Emergency Health Care Services outside of our Service Area, you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition ...
Emergency Health Care Services. 4.16.5.1 The Contractor shall not deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or
4.16.5.2 Make payment for emergency health care services contingent on the recipient or provider of emergency health care services providing any notification, either before or after receiving emergency health care services.
4.16.5.3 In processing claims for emergency health care services, a care management organization shall consider, at the time that a claim is submitted, at least the following criteria: · The age of the patient; · The time and day of the week the patient presented for services; · The severity and nature of the presenting symptoms; · The patient’s initial and final diagnosis; and · Any other criteria prescribed by DCH, including criteria specific to patients less than 18 years of age.
4.16.5.4 The Contractor shall configure or program its automated claims processing system to consider at least the conditions and criteria described in this subsection for claims presented for emergency health care services.
4.16.5.5 If a provider that has not entered into a contract with a care management organization provides emergency health care services or post-stabilization services to that care management organization’s member, the care management organization shall reimburse the non contracted provider for such emergency health care services and post-stabilization services at a rate equal to the rate paid by DCH for Medicaid claims that it reimburses directly.
Emergency Health Care Services. Benefits for treatment of Emergency medical conditions and Emergency screening and Stabilization services without Prior Authorization for conditions that reasonably appear to a prudent layperson to constitute an Emergency medical condition based upon the patient’s presenting symptoms and conditions. Benefits for Emergency Care include facility costs and Physician services, and supplies and Prescription Drugs charged by that facility.
Emergency Health Care Services. Care planning in relation to sudden illness should begin as part of the admission process. You acknowledge receipt of Clearview’s written policy related to the use of life-sustaining procedures, CPR and comfort measures. You authorize Clearview to obtain emergency health care services when services are required and your health care provider or alternate is unavailable.
Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, seven days per week, when those services are needed immediately to prevent jeopardy to your health. You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network (outside of the 5-county area) facility at the In-network benefit level. Whether Out-of-network (outside of the 5-county area) Emergency Health Care Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person
Emergency Health Care Services. The City shall provide immediate emergency health care services to faculty and students participating in the program in the event of accidental injury or illness while on the City's premises. At the time of providing such services, the City shall accept assignment of the affected individual's insurance policy. The City shall not be responsible for costs involved in the provision of such services, the follow- up care, or hospitalization.
Emergency Health Care Services. (a) If we determine that the Health Care Services were not an Emergency, the Health Care Services are Non-Covered Services and you will be responsible for costs associated with the Health Care Services.
(b) Subsequent follow up care by a Non-Participating Provider after the condition is no longer an Emergency is a Non-Covered Service unless specifically authorized by us.
(c) If a Covered Person is hospitalized in a Non-Participating Hospital due to an Emergency, you or the Provider must notify us within 48 hours of the admission. A continued stay after the condition is stabilized and is no longer an Emergency requires our written authorization. We may elect to transfer the Covered Person to a Participating Hospital once it is medically appropriate to do so.
Emergency Health Care Services. 4.16.5.1 The Contractor shall not deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or
4.16.5.2 Make payment for emergency health care services contingent on the recipient or provider of emergency health care services providing any notification, either before or after receiving emergency health care services.
4.16.5.3 In processing claims for emergency health care services, a care management organization shall consider, at the time that a claim is submitted, at least the following criteria:
4.16.5.3.1 The age of the patient;
4.16.5.3.2 The time and day of the week the patient presented for services;
4.16.5.3.3 The severity and nature of the presenting symptoms;
4.16.5.3.4 The patient’s initial and final diagnosis; and
4.16.5.3.5 Any other criteria prescribed by the Department of Community Health, including criteria specific to patients under 18 years of age.
4.16.5.4 The Contractor shall configure or program its automated claims processing system to consider at least the conditions and criteria described in this subsection for claims presented for emergency health care services.
4.16.5.5 If a provider that has not entered into a contract with a care management organization provides emergency health care services or post-stabilization services to that care management organization’s member, the care management organization shall reimburse the non contracted provider for such emergency health care services and post-stabilization services at a rate equal to the rate paid by the Department of Community Health for Medicaid claims that it reimburses directly.
Emergency Health Care Services. Benefits for treatment of Emergency medical conditions and Emergency screening and Stabilization services without Prior Authorization for conditions that reasonably appear to
Emergency Health Care Services. 4.16.5.1 The Contractor shall not deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or Revised 5/19/2008 Page 126 of 234
4.16.5.2 Make payment for emergency health care services contingent on the recipient or provider of emergency health care services providing any notification, either before or after receiving emergency health care services.
4.16.5.3 In processing claims for emergency health care services, a care management organization shall consider, at the time that a claim is submitted, at least the following criteria:
4.16.5.3.1 The age of the patient;
4.16.5.3.2 The time and day of the week the patient presented for services;
4.16.5.3.3 The severity and nature of the presenting symptoms;
4.16.5.3.4 The patient's initial and final diagnosis; and
4.16.5.3.5 Any other criteria prescribed by the Department of Community Health, inlcuding criteria specific to patients under 18 years of age.
4.16.5.4 The Contractor shall configure or program its automated claims processing system to consider at least the conditions and criteria described in this subsection for claims presented for emergency health care services.
4.16.5.5 If a provider that has not entered into a contract with a care management organization provides emergency health care services or post-stabilization services to that care management organization's member, the care management organization shall reimburse the non contracted provider for such emergency health care services and post-stabilization services at a rate equal to the rate paid by the Department of Community Health for Medicaid claims that it reimburses directly.
