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Provider Manual

Emergency Medical Care Services

Last Updated on August 28, 2018

Emergency medical care is medical services provided by a health care provider to treat an emergency medical condition. An emergency medical condition means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent lay person who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:

  • Serious jeopardy to the participant’s health, or with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child; 
  • Serious impairment to the member’s bodily functions; or 
  • Serious dysfunction of one or more of the member’s body organs or parts 

For example, such conditions include heart attack, stroke, poisoning, loss of consciousness or loss of breathing.

Members should use affiliated hospital emergency rooms whenever possible. If members are unable to reach an affiliated provider, they should go to the nearest appropriate medical facility. If they must go to a nonaffiliated provider for care, by the next business day or as soon as possible, they should call 1-800-472-2363 and tell Security Health Plan where they are receiving/did receive emergency medical care. Follow-up care must be received from an affiliated provider unless otherwise authorized by Security Health Plan. Emergency care received from a nonaffiliated provider will be covered at the same level of benefits as services provided by an affiliated provider. Benefits are subject to copayment, coinsurance, deductibles and other provisions of the members’ policies.

Urgent care services

Urgent care is care that is needed sooner than a routine doctor’s visit. When members are in the service area, benefits are payable for urgent care services only when provided by an affiliated provider. If members are outside the service area and cannot safely postpone the care until they can return to the service area, benefits are payable for services received at the nearest appropriate medical facility. Members should notify Security Health Plan at 1-800-472-2363 prior to receiving the care, but no later than the next business day, to ensure appropriate claim payment. Benefits are subject to copayment, coinsurance, deductible and other provisions of the members’ policies.

Members living outside the service area

Dependents, including full-time students, residing outside the service area who require emergency care when in the area should go to the nearest medical facility for emergency medical care. They may obtain urgent care services from nonaffiliated providers if the medical care cannot be safely postponed until they can return to the service area. Lack of transportation to see an affiliated provider is not considered a reason for urgent care. Security Health Plan should be notified before members receive the care, the next business day, or as soon as reasonably possible, to ensure claim payment is appropriate. For additional coverage to be provided, any other care must be obtained from affiliated providers unless the member receives prior written authorization from Security Health Plan. Benefits are subject to copayment, coinsurance, deductibles and other provisions of the members’ policies.