Emergency or Urgently Needed Care. 1. In the event a complaint requires specific action, and the Member or HMO believes serious medical consequences will arise in the near future, within up to 15 days from HMO’s denial to pay for the provision of allegedly Medically Necessary covered health services, the Member shall receive expedited review of their complaint.
2. In the event the issue is of an emergent nature, an HMO Medical Director shall review the matter as soon as possible or within 48 hours, and communicate a decision to the Member by telephone.
3. In the event the issue is of an urgent nature, an HMO Medical Director shall review the matter and make a determination within 96 hours of receipt.
4. An adverse decision by a Medical Director in either an emergent or urgent medical situation shall be immediately reviewed by an HMO Regional Medical Director or his designee. The decision of the Regional Medical Director shall be provided to the Member by telephone and confirmed in writing.
Emergency or Urgently Needed Care. CHA PACE covers emergency or urgent care within the United States (only) when you are temporarily out of the service area for a period up to 30 days. If you are out of CHA PACE service area for more than 30 consecutive days, you will be automatically disenrolled, pending MassHealth review and final determination, unless prior arrangements have been approved. • the care you receive is needed as a result of an unforeseen illness, injury or condition • your illness or injury requires medical attention to prevent serious deterioration in your health • you cannot delay necessary medical attention until you return to the service area Prior authorization is not needed for emergency care. However, out of area urgently needed services do require that CHA PACE provide authorization. If CHA PACE does not respond to a request for approval of urgent care within one hour after being contacted, it is deemed authorized. If you are hospitalized when you are out of the service area, you should notify CHA PACE as soon as possible. If you have paid for the emergency or urgent medical services you received out of the CHA PACE area, you should request a receipt from the facility or physician involved. This receipt must show the physician’s name, date of treatment and release, and charges. Please send a copy of the receipt to CHA PACE at 000 Xxxx Xxxxxx, Cambridge, MA 02141 for reimbursement. CHA PACE will not bill CMS or MassHealth for any costs associated with emergency care. CHA PACE does not cover medical care provided outside the United States. Please call CHA PACE, (000) 000-0000, with questions and for exceptions. • Cosmetic surgery unless required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy. • Experimental, medical, surgical or other health treatments or procedures not generally accepted medical practice in the geographic area, as determined by CHA PACE Medical Director. • Any services rendered outside the United States, with exceptions. Please contact CHA PACE at (000) 000-0000. Before you leave the CHA PACE service area, you should notify CHA PACE. CHA PACE will explain what to do if you become ill or injured while away from the CHA PACE service area. If you are hospitalized when you are out of the CHA PACE service area, you should notify CHA PACE within 48 hours or as soon as it is reasonably possible to do so. • At least 55 years of age. • Capable of safely residing in the com...
Emergency or Urgently Needed Care. 1. In the event a complaint requires specific action, and the Member or HMO believes serious medical consequences will arise in the near future, or the Member’s ability to regain maximum function is jeopardized, the Member may request an expedited review of their complaint. The HMO in consultation with an HMO Medical Director shall provide an expedited review and HMO shall communicate its decision in writing to the Member and the Member’s Provider within 4 days after receiving information justifying the expedited appeal. If the expedited review is a concurrent review determination, HMO shall remain liable for the coverage of health care services until the Member has been notified of the determination. HMO is not required to provide an expedited review for retrospective noncertifications.
2. In the event the issue is of an emergent nature, an HMO Medical Director shall review the matter as soon as possible or within 48 hours, and communicate a decision to the Member by telephone.
3. In the event the issue is of an urgent nature, an HMO Medical Director shall review the matter and make a determination within 96 hours of receipt.
4. An adverse decision by a Medical Director in either an emergent or urgent medical situation shall be immediately reviewed by an HMO Regional Medical Director or his designee. The decision of the Regional Medical Director shall be provided to the Member by telephone and confirmed in writing.
