Emergency care & post-stabilization services (Medicaid)

Applies to: 

Medicaid

Definitions

Emergency medical condition

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) 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: 

1. Placing the health of the individual — or, for a pregnant woman, the health of the woman or her unborn child — in serious jeopardy
2. Serious impairment to bodily functions
3. Serious dysfunction of any bodily organ or part

Emergency services

Covered inpatient and outpatient services, including mental health services, that are furnished to an enrollee by a provider who is qualified to furnish such services under Title XIX of the Social Security Act, and are needed to evaluate or stabilize an enrollee’s emergency medical condition.Post-stabilization care servicesCovered services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition and improve or resolve the enrollee’s condition.

Emergency department coverage and payment 

Emergency services are covered regardless of whether the provider furnishing the services is in or out of network.

Priority Health will still provide payment for treatment if the following occurs:

• After treatment, it’s determined that the absence of treatment wouldn’t have resulted in serious bodily harm or any of the conditions detailed in the definition of “Emergency medical condition” 
• A Priority Health representative directs the member to seek emergency services
• The emergency room provider, hospital or fiscal agent doesn’t notify the member’s primary care provider (PCP) or health plan of the member’s screening and treatment within 10 calendar days of presentation for emergency services

Priority Health won’t limit what constitutes an emergency medical condition to a list of diagnoses or symptoms. 

Post-stabilization coverage and payment

A member experiencing an emergency medical condition won’t be liable for payment for a follow-up screening and the treatment needed to diagnose a specific condition or stabilize the member. The attending emergency physician and/or treating physician is responsible for determining when the member is stabilized for transfer or discharge.

Post-stabilization services are covered, both in or out-of-network, with prior authorization.  Services without prior authorization will be covered when:

• Post-stabilization care services have been administered to maintain the member’s condition within one hour of a request for pre-approval of further post-stabilization services
• Post-stabilization care services have been administered to maintain, improve or resolve the member’s condition, and response to prior approval wasn’t provided within one hour
• The provider cannot reach a representative — or, an agreement between the representative and treating physician cannot be reached — and a plan physician isn’t available for consultation

The treating physician will be given the opportunity to consult with a plan physician and may continue with care of the patient until a plan physician is reached, or one of the criteria is met:

• The plan physician assumes responsibility for care through transfer
• Priority Health and the treating physician reach an agreement on the member’s care
• The member is discharged

After criteria has been met, the health plan’s responsibility for covering services not pre-approved will end. A Priority Health physician with hospital privileges will then assume responsibility for the member’s care.