New Claims System Update

6.4 Emergency Care

Provider Manual
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6 PROVIDER NETWORK INFORMATION

6.4 Emergency Care

An emergency medical condition is 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:

  • 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.

    • IntegraNet covers emergency services if they are:

  • Furnished by a provider qualified to provide emergency services.
  • Needed to evaluate or stabilize an emergent medical condition in accordance with the prudent layperson standard.

    • Members with an emergency medical condition should be instructed to call 911 and/or go to the nearest emergency hospital. Precertification for an emergency medical condition is not required.