Common use of Emergency Room Benefits Clause in Contracts

Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services within the Primary Care Physician service area (e.g., suture removal, wound check, etc.) must be authorized by Blue Shield or obtained through the Member’s Primary Care Physician. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive emergency admission notification within 24 hours or as soon as it is reasonably possible following medi- cal stabilization. The services will be reviewed retro- spectively by Blue Shield to determine whether the services were for an Emergency Medical Condition. Services Provided at a Non-Plan Hospital Following Stabilization of an Emergency Medical Condition When the Member’s Emergency Medical Condition is stabilized, and the treating health care provider at the non-Plan Hospital believes additional Medically Necessary Hospital services are required, the non- Plan Hospital must contact Blue Shield to obtain timely authorization. Blue Shield may authorize con- tinued Medically Necessary Hospital services by the non-Plan Hospital. If Blue Shield determines the Member may be safely transferred to a Hospital that is contracted with the Plan and the Member refuses to consent to the trans- fer, the non-Plan Hospital must provide the Member with written notice that the Member will be xxxxx- cially responsible for 100% of the cost for services provided following stabilization of the Emergency Medical Condition. As a result, the Member may be billed by the non-Plan Hospital. Members should contact Shield Concierge at the number provided on the back page of the EOC for questions regarding im- proper billing for services received from a non-Plan Hospital. For information on Emergency Services received outside of California, see the Inter-Plan Arrange- ments section of the EOC. Family Planning and Infertility Benefits Benefits are provided for the following fam- ily planning services without illness or injury be- ing present:

Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services within the Primary Care Physician service area (e.g., suture removal, wound check, etc.) must be authorized by Blue Shield or obtained through the Member’s Primary Care Physician. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive emergency admission notification within 24 hours or as soon as it is reasonably possible following medi- cal stabilization. The services will be reviewed retro- spectively by Blue Shield to determine whether the services were for an Emergency Medical Condition. Services Provided at a Non-Plan Hospital Following Stabilization of an Emergency Medical Condition When the Member’s Emergency Medical Condition is stabilized, and the treating health care provider at the non-Plan Hospital believes additional Medically Necessary Hospital services are required, the non- Plan Hospital must contact Blue Shield to obtain timely authorization. Blue Shield may authorize con- tinued Medically Necessary Hospital services by the non-Plan Hospital. If Blue Shield determines the Member may be safely transferred to a Hospital that is contracted with the Plan and the Member refuses to consent to the trans- fer, the non-Plan Hospital must provide the Member with written notice that the Member will be xxxxx- cially responsible for 100% of the cost for services provided following stabilization of the Emergency Medical Condition. As a result, the Member may be billed by the non-Plan Hospital. Members should contact Shield Concierge at the number provided on the back page of the EOC for questions regarding im- proper billing for services received from a non-Plan Hospital. For information on Emergency Services received outside of California, see the Inter-Plan Arrange- ments section of the EOC. Family Planning and Infertility Benefits Benefits are provided for the following fam- ily planning services without illness or injury be- ing present:Benefits

Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services within the Primary Care Physician service area (e.g., suture removal, wound check, etc.) must be prior authorized by Blue Shield or obtained through the Member’s Primary Care Personal Physician. Emergency Services are services provided for an Emergency Medical Conditionunexpected medical condition, including a psy- chiatric Emergency Medical Condition or active laborpsychiatric emergency medical condition, manifesting itself by acute symptoms of suf- ficient sufficient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably reasonably be expected to result in any of the follow- ingfollowing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tionsfunctions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive emergency admission notification within 24 hours or as soon as it is reasonably possible following medi- cal stabilization. The services will be reviewed retro- spectively by Blue Shield to determine whether the services were for an Emergency Medical Condition. Services Provided at a Non-Plan Hospital Following Stabilization of an Emergency Medical Condition When the Member’s Emergency Medical Condition medical condition is stabilized, and the treating health care provider at the non-Plan Hospital believes additional Medically Necessary Hospital services are required, the non- non-Plan Hospital must contact Blue Shield to obtain timely authorization. Blue Shield may authorize con- tinued continued Medically Necessary Hospital services by the non-Plan Hospital. If Blue Shield determines the Member may be safely transferred to a Hospital that is contracted with the Plan and the Member refuses to consent to the trans- fertransfer, the non-Plan Hospital must provide the Member with written notice that the Member will be xxxxx- cially financially responsible for 100% of the cost for services provided following stabilization of the Emergency Medical Conditionemergency medical condition. As a result, the Member may be billed by the non-Plan Hospital. Members should contact Shield Concierge at the number provided on the back page of the EOC Evidence of Coverage for questions regarding im- proper improper billing for services received from a non-Plan Hospital. For information on Emergency Services received outside of California, see the Inter-Plan Arrange- ments section of the EOC. Family Planning and Infertility Benefits Benefits are provided for the following fam- ily planning services without illness or injury be- ing present:.