Emergency Services - An Emergency. Service is any health care service provided to a Member after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: Placing the health of the Member, or with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; or Other serious medical consequences. Benefits for Emergency Services include the initial evaluation, treatment and related services, such as diagnostic procedures provided on the same day as the initial treatment. Inpatient Hospital stays as a result of an emergency are reimbursed at the level of payment for Inpatient Benefits. Observation status is not considered Inpatient admission. Emergency room Cost- Sharing Amounts will apply to observational care unless the Member is admitted Inpatient. Consultations received in the emergency room are subject to the applicable Outpatient consultation Copayment. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in-network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Benefits for emergency dental accident services include treatment required only to stabilize the Member immediately following an accidental injury. Treatment of accidental injuries resulting from chewing or biting is not covered. If Keystone, upon reviewing the emergency room records, determines that the services provided do not qualify as Emergency Services, those non-emergency services may not be covered or may be reduced according to the limitations of this coverage.
