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Provider Manual

Emergency and Urgently Needed Care Coverage

Last Updated on August 28, 2018

Definitions

Security Health Plan Medicare Advantage defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

  • serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child
  • serious impairment to bodily functions
  • serious dysfunction of any bodily organ or part

“Emergency services” are inpatient or outpatient covered services that are furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.

Emergency services are covered, whether or not they are provided by an affiliated provider.

Services after a member is stable are not emergency services.

Security Health Plan defines “urgently needed services” as a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care.. Urgent care is not emergency care. Urgently needed services are covered within the Medicare Advantage plan service area only if provided by a network provider. Urgent care may be provided by a non-affiliated provider when a member is temporarily absent* from the Medicare Advantage service area (or, under unusual and extraordinary circumstances, when the member is in the Medicare Advantage service area but an affiliated provider is temporarily unavailable or inaccessible). Such services must be medically necessary and immediately required, and are a result of an unforeseen illness, injury, or condition; and it is not reasonable, given the circumstances, to obtain services through an affiliated provider.

* A temporary absence is an absence from the Medicare Advantage service area lasting not more than 6 months.

Emergency Services Within the Medicare Advantage Service Area

In the event of an emergency, the member should be instructed to go to the nearest emergency room or to the nearest Security Health Plan
Medicare Advantage affiliated hospital, or call 911, or the emergency access number for the member’s area for assistance. Affiliated hospital emergency rooms should be used whenever possible. Medicare Advantage members are asked to notify Security Health Plan within 48 hours of the emergency, or as soon as possible. If the emergency occurs within the service area, all follow-up care must be obtained through contracted network providers.

Noncoverage Specifics

Specific benefits, limitations, and exclusions are set forth in the Evidence of Coverage issued to each member. In general, covered services must be received from Security Health Plan affiliated providers.  Emergency services or urgent care services needed outside the service area are a covered benefit. For all other care, benefits are available from nonaffiliated providers only if covered services are not available from affiliated providers. Security Health Plan member or other provider should contact Security Health Plan prior to receiving nonaffiliated provider services to determine coverage. Members are financially responsible for nonaffiliated provider services that have not been prior authorized by Security Health Plan. Except as described above, services provided by nonaffiliated providers will not be covered. Members who have purchased the Advocare Point of Service rider may have some benefits from nonaffiliated providers.