TREATMENT OF AN EMERGENCY Sample Clauses

TREATMENT OF AN EMERGENCY. If you are more than 30 miles away from your Participating IPA/Participating Medical Group and need to obtain treatment for an Emergency Condition, bene­ fits will be provided for the Hospital and Physician services that you receive. Benefits are available for the initial treatment of the emergency and for related follow‐up care but only if it is not reasonable for you to obtain the follow‐up care from your Primary Care Physician or Woman's Principal Health Care Provider. If you are not sure whether or not you are in your Participating IPA's/Participating Medical Group's treatment area, call them and they will tell you.
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TREATMENT OF AN EMERGENCY. If you are more than 30 miles away from your Participating IPA/Participating Medical Group and need to obtain treatment for an Emergency Condition, bene­ GB‐16 HCSC 50 fits will be provided for the Hospital and Physician services that you receive. Benefits are available for the initial treatment of the emergency and for related follow‐up care but only if it is not reasonable for you to obtain the follow‐up care from your Primary Care Physician or Woman's Principal Health Care Provider. If you are not sure whether or not you are in your Participating IPA's/Participating Medical Group's treatment area, call them and they will tell you.
Sample 1
TREATMENT OF AN EMERGENCY. You are considered to be in your Participating IPA's/Participating Medical Group's treatment area if you are within 30 miles of your Participating IPA/Par­ ticipating Medical Group. Although you may go directly to the nearest Hospital emergency room to obtain treatment for an Emergency Condition, we recommend that you contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider first if you are in your Participating IPA's/Participating Medical Group's treatment area. If you obtain emergency treatment in the Hospital emergency room, your Primary Care Physician or Woman's Principal Health Care Provider must be notified of your condition as soon as possible and benefits will be limited to the initial treat­ ment of your emergency unless further treatment is ordered by your Primary Care Physician or Woman's Principal Health Care Provider. If Inpatient Hospital care is required, it is especially important for you or your family to contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider as soon as possible. All Participating IPA's/Participating Medical Groups have 24 hour phone service. Payment for In‐Area Emergency Treatment Benefits for emergency treatment received in your Participating IPA's/Participat­ ing Medical Group's treatment area will be paid at 100% of the Provider's Charge. However, each time you receive emergency treatment in a Hospital emergency room, you will be responsible for a Copayment of $75. The emergency room Co­ payment does not apply to services provided for the treatment of sexual assault. Should you be admitted to the Hospital as an Inpatient, benefits will be paid as explained in the Hospital Benefits and Physician Benefits Sections of this Certi­ ficate. If you are admitted to the Hospital as an Inpatient immediately following emergency treatment, the emergency room Copayment will be waived.
Sample 1

Related to TREATMENT OF AN EMERGENCY

  • Medical Emergency A medical condition which manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in 1) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. Examples of a medical emergency are severe pain, suspected heart attacks and fractures. Examples of a non- medical emergency are minor cuts and scrapes. Medically Necessary and Medical Necessity Services a physician, exercising prudent clinical judgment, would use with a patient to prevent, evaluate, diagnose or treat an illness or injury or its symptoms. These services must:  Agree with generally accepted standards of medical practice  Be clinically appropriate in type, frequency, extent, site and duration., They must also be considered effective for the patient’s illness, injury or disease  Not be mostly for the convenience of the patient, physician, or other healthcare provider. They do not cost more than another service or series of services that are at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer reviewed medical literature. This published evidence is recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. Member Any person covered under this plan. Mental Condition A condition that is listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This does not include conditions and treatments for chemical dependency. Mental Health Services Medically necessary outpatient and inpatient services provided to treat mental conditions. State and federal law require that the copays and coinsurance for mental health services will be no more than the copays and coinsurance for medical and surgical services. Prescription drugs for mental conditions are covered under the same terms and conditions as other prescription drugs covered under this plan.

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