9 Hospital and Elective Admission Management
9.4 Emergency Services
When a member seeks emergency services at a hospital, the determination as to whether the need for those services exists will be made for purposes of treatment by a physician licensed to practice medicine or, to the extent permitted by applicable law, by other appropriately licensed personnel under the supervision of or in collaboration with a physician licensed to practice medicine. IntegraNet will compensate the provider for the screening, evaluations and examinations that are reasonable and calculated to assist the health care provider to determine whether or not the patient’s condition is an emergency medical condition.
If there is concern surrounding the transfer of a patient (i.e., whether the patient is stable enough for discharge or transfer or whether the medical benefits of an unstable transfer outweigh the risks), the judgment of the attending physician(s) caring for the member at the treating facility prevails and is binding on IntegraNet. If the emergency department is unable to stabilize and release the member, IntegraNet will assist in coordination of the inpatient admission regardless of whether the hospital is network or nonnetwork. All transfers from non-network to network facilities are to be conducted only after the member is medically stable and the facility is capable of rendering the required level of care.
If the member is admitted, the IntegraNet concurrent review nurse will implement the concurrent review process to ensure coordination of care.