Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare 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 facility at the In-network benefit level. Whether Out-of-network Emergency Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare 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 • Any circumstance that prevented you from using our established procedures for obtaining Emergency Healthcare Services Coverage for trauma services and all other Emergency Healthcare Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In- network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Healthcare Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency.
Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, 7 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 facility at the In-network benefit level. Whether Out-of-network Emergency Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare 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 Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Healthcare 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 Healthcare 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 healthcare 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 Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, seven (7) 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 Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare 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 • Any circumstance that prevented you from using our established procedures for obtaining Emergency Healthcare Services Coverage for trauma services and all other Emergency Healthcare Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In- network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Healthcare Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Healthcare Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coins...
