Observation Services. This plan covers services provided to you when you are in a hospital or other licensed health care facility solely for observation. Even though you may use a bed or stay overnight, observation services are not inpatient services. Observation services help the physician decide if you need to be admitted for care as an inpatient or if you can be discharged. These observation services may be provided in the emergency room or another area of the hospital or licensed healthcare facility. See the Summary of Medical Benefits for the amount you pay.
Observation Services. In a hospital or other health care facility 0% - After deductible 20% - After deductible
Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equip...
Observation Services. This plan covers services provided to you when you are in a hospital or other licensed health care facility solely for observation. Even though you may use a bed or stay overnight, observation services are not inpatient services. Observation services help the physician decide if you need to be admitted for care as an inpatient or if you can be discharged. These observation services may be provided in the emergency room or another area of the hospital or licensed healthcare facility. Observation services received from a non-network provider that are related to an emergency room service are covered at a network level of benefits as described in Section 6. See the Summary of Medical Benefits for the amount you pay.
Observation Services. In a hospital or other health care facility 10% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 10% - After deductible Not Covered Hospital based clinic visits $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered Retail clinics $45 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Organ Transplants Organ transplant services 10% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered
Observation Services. In a hospital or other health care facility 10% - After deductible Not Covered
Observation Services. Observation Services are Outpatient services provided by a Hospital and a Provider on the Hospital’s premises. These services may include the use of a bed and monitoring by a Hospital’s nursing staff that are reasonable and necessary to evaluate Your Condition, determine the need for a possible admission to the Hospital, or when rapid improvement of the Your Condition is expected. When a Hospital places You under Outpatient Observation, it is based upon the Provider’s written order. To move from Observation to an Inpatient admission, Our level of care criteria must be met. The length of time spent in the Hospital is not the only factor determining Observation instead of an Inpatient stay. Medical criteria will also be considered. All Accidental Injury (trauma), Urgent Care, Emergency Care Services, and Observation Services whether provide within or outside of the Plan’s Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Acquired Brain Injury The Plan covers treatment of an Acquired Brain Injury on the same basis as treatment for any other physical condition. Cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy, and rehabilitation; neurobehavioral, neuropsychological, neurophysiological and psychophysiological testing and treatment; neuro feedback and remediation therapy, post-acute transition and reintegration services, or other treatment services are covered if such services are Medically Necessary as a result of and related to an Acquired Brain Injury. Ambulance Services The Plan covers the following types of Ambulance Services: (1) Emergency Ambulance Services,
Observation Services. Observation services are services received in an outpatient facility setting, which are reasonable and necessary to evaluate an outpatient condition or determine the need for possible inpatient admission to the Facility. Observation services exceeding 48 hours are not reimbursable under this Agreement. Observation stays greater than or equal to 23 hours, for which Facility chooses to xxxx as an inpatient service, require authorization from Cenpatico. Reimbursement for the inpatient admission includes the observation stay.
Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay
Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $30 Not Covered Enhanced $15 Not Covered Retail clinics $30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. $40 Not Covered
