If You Have a Medical Emergency. If you need Medical Emergency services, you should go immediately to the nearest emergency department or call 9-1-1 or another local emergency number. You do not need a Referral or Prior Approval for Medical Emergency services. Medical Emergencies include, but are not limited to: • Heart attack; • Stroke; • Severe trauma; • Shock; • Loss of consciousness; • Seizures; and • Convulsions. Once your emergency medical condition is stabilized, Notification and Prior Approval requirements apply. If you are hospitalized, Notification to Health Options via our Member Services toll free number at 1-855-624-6463 is required within 48 hours of the admission. When you are admitted to a Network Provider facility, the staff at that facility is required to notify Health Options of your admission. If you are admitted to a Non-Network Provider facility, you or your designee is required to notify your PCP and Health Options within 48 hours of admission. Your PCP will arrange for any follow-up care you may need. Your emergency department Out-of-Pocket Costs are listed on the Schedule of Benefits. If you are admitted to the Hospital from the emergency department, your Out-of-Pocket Costs for the emergency department visit as outlined in the Schedule of Benefits will be waived. Should you seek Medical Emergency services at a Hospital that is a Non-Network Provider, your Out-of-Pocket Costs for the Maximum Allowable Amount, as determined by Health Options (see section 6 for more info), will be at the Network Provider (or In-Network) cost-sharing level. You may be responsible for charges above the Maximum Allowable Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Refer to Section 2.B for information regarding Hospital admissions.
