Common use of Emergency Healthcare Services Clause in Contracts

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, 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, 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 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.

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.. 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, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost-Sharing amount. For Emergency Healthcare Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Healthcare Services from the nearest appropriate facility where Emergency Healthcare Services can be rendered. Non-emergent follow-up care received outside of New Mexico is not Covered unless transfer to an In-network Practitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Healthcare Services. Non-emergent follow-up care outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider requires our Prior Authorization. Observation Services‌ 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 is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are:‌‌ • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring healthcare professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

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. 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, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost-Sharing amount. For Emergency Healthcare Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Healthcare Services from the nearest appropriate facility where Emergency Healthcare Services can be rendered. Non-emergent follow-up care received outside of New Mexico is not Covered unless transfer to an In-network Practitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Healthcare Services. Non-emergent follow-up care outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider requires our Prior Authorization.

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 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, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Healthcare Services received Out-of-network (outside of the 5-county area) and/or outside of New Mexico (our Service Area), you may seek Emergency Healthcare Services from the nearest appropriate facility where Emergency Healthcare Services can be rendered. Non-emergent follow-up care received outside of the 5-county area is not Covered unless transfer to an In-network Practitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Healthcare Services. Non-emergent follow-up care outside of the 5-county area is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network (outside of the 5-county area) Practitioner/Provider requires our Prior Authorization.