Common use of Notification for Emergency Hospital Admissions Clause in Contracts

Notification for Emergency Hospital Admissions. Hospital admissions directly from the emergency room do not require Pre-Authorization. However, notification is required within 2 business days after the Hospital admission when admitted directly from the emergency room, or as soon as possible. You, or your Provider, may notify us by calling the Notification of Hospital Admission phone number located on the back of your ID card. Concurrent Review and Discharge Coordination Continued hospitalization is subject to periodic clinical review to ensure timely, quality care in the appropriate setting. Discharge coordination assists those transferring from the Hospital to home or another Facility. Case Management A catastrophic medical condition is a condition that requires lengthy hospitalization, extremely expensive therapies, or other care that would deplete a family's financial resources. A catastrophic medical condition may require long- term and perhaps lifetime care, often involving extensive services in a Facility or at home. With case management, a nurse case manager or Master’s prepared licensed therapist monitors a patient with a catastrophic medical condition, and explores coordinated and/or alternative types of appropriate care. The case manager consults with the patient, family, and attending physician to develop a plan of care that may include: • Offering personal support to the patient; • Contacting the family for assistance and support; • Monitoring Hospital or Skilled Nursing Facility stays; • Addressing alternative care options; • Assisting in obtaining any necessary equipment and services; and • Providing guidance and information on available resources. Case management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Each treatment is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis. The final decision on the course of treatment rests with patients and their Providers. 24-Hour Nurse Advice Line You can call the free Nurse Advice Line to get health care information 24 hours a day, 7 days a week. The nurses can help you when you have questions about health concerns or need health information. To speak to a nurse, call toll free 0-000-000-0000 or TTY Relay: Dial 7-1-1 for speech or hearing impaired. Second Opinions A second opinion by a qualified Provider regarding any medical diagnosis or treatment plan is covered by this plan. Coverage, including the amounts you are responsible to pay for Covered Services and supplies (“Cost-Shares”), depends on whether you see an In-Network or Out-of-Network Provider. Please see the Cost Shares section. COST-SHARES‌ This section of your Agreement explains the types of expenses you must pay for Covered Services before the benefits of this plan are provided (“Cost-Shares”). To prevent unexpected Out-of-Pocket Expenses, it is important for you to understand what amounts you are responsible for. Copayments Copayments (referred to as “Copays”) are fixed, up-front dollar amounts that you are required to pay at the time and place you receive a service or supply. Specific Copay amounts are located under the Schedule of Medical Benefits section. Payment of a Copay does not exclude the possibility of being billed for additional charges if the service is determined not to be a Covered Service.

Notification for Emergency Hospital Admissions. Hospital admissions directly from the emergency room do not require Pre-Authorizationpre‐authorization. However, notification is required within 2 two (2) business days after the Hospital admission when admitted directly from the emergency room, or as soon as possible. You, or your Provider, may notify us by calling the Notification of Hospital Admission phone number located on the back of your ID card. Concurrent Review and Discharge Coordination Continued hospitalization is subject to periodic clinical review to ensure timely, quality care in the appropriate setting. Discharge coordination assists those transferring from the Hospital to home or another Facility. Case Management A catastrophic medical condition is a condition that requires lengthy hospitalization, extremely expensive therapies, or other care that would deplete a family's financial resources. A catastrophic medical condition may require long- term and long‐ term, perhaps lifetime care, often care involving extensive services in a Facility or at home. With case management, a nurse case manager or Master’s prepared licensed therapist monitors a patient with a catastrophic medical condition, these patients and explores coordinated and/or alternative types of appropriate care. The case manager consults with the patient, family, and attending physician to develop a plan of care that may include: •  Offering personal support to the patient; •  Contacting the family for assistance and support; •  Monitoring Hospital or Skilled Nursing Facility stays; •  Addressing alternative care options; •  Assisting in obtaining any necessary equipment and services; and •  Providing guidance and information on available resources. Case management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Each treatment is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis. The final decision on the course of treatment rests with patients and their Providers. 24-Hour Nurse Advice Line You can call the free Nurse Advice Line to get health care information 24 hours a day, 7 days a week. The nurses can help you when you have questions about health concerns or need health information. To speak to a nurse, call toll free 0-000-000-0000 or TTY Relay: Dial 7-1-1 for speech or hearing impaired. Second Opinions A second opinion by a qualified Provider regarding any medical diagnosis or treatment plan is covered by this plan. Coverage, including the amounts you are responsible to pay for Covered Services and supplies (“Cost-Shares”), depends on whether you see an In-Network or Out-of-Network Provider. Please see the Cost Shares section. COST-SHARES‌ This section of your Agreement explains the types of expenses you must pay for Covered Services before the benefits of this plan are provided (“Cost-Shares”). To prevent unexpected Out-of-Pocket Expenses, it is important for you to understand what amounts you are responsible for. Copayments Copayments (referred to as “Copays”) are fixed, up-front dollar amounts that you are required to pay at the time and place you receive a service or supply. Specific Copay amounts are located under the Schedule of Medical Benefits section. Payment of a Copay does not exclude the possibility of being billed for additional charges if the service is determined not to be a Covered Service.