Medical Emergencies & Urgent Care
Getting care if you have a medical emergency or an urgent need for care
What is a “medical emergency”?
A “medical emergency” is when you believe that your health is in serious danger. A medical emergency includes severe pain, a
bad injury, a sudden illness, or a medical condition that is quickly getting much worse.
If you have a medical emergency:
- Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center.
You do not need to get approval or a referral first from your doctor or other network provider.
- As soon as possible, make sure that we know about your emergency, because we need to be involved in following up on your emergency
care. You or someone else should call to tell us about your emergency care as soon as possible, usually within 48 hours. Please
call your PCP’s office at the number located on your membership I.D. card.
We will talk with the doctors who are giving you emergency care to help manage and follow up on your care. When the doctors who
are giving you emergency care say that your condition is stable and the medical emergency is over then you are still entitled
to follow-up post stabilization care. Your follow-up post stabilization care will be covered according to Medicare guidelines.
In general, if your emergency care is provided out of network we will try to arrange for network providers to take over your
care as soon as your medical condition and the circumstances allow.
What is covered if you have a medical emergency?
You may get covered emergency medical care whenever you need it, anywhere in the United States.
You may get covered emergency medical care wherever you need it, world wide.
Ambulance services are covered in situations where other means of transportation in the United States would endanger your health.
(See the benefits chart in the EOC for more detailed information.)
What if it was not a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking
that your health is in serious danger – and the doctor may say that it was not a medical emergency after all. If this happens,
you are still covered for the care you got to determine what was wrong, as long as you thought your health was in serious danger,
as explained in “What is a medical emergency?” above. If you get any extra care after the doctor says it was not a medical emergency,
the Plan will pay its portion of the covered additional care only if you get it from a network provider. We will pay our portion
of the covered additional care from an out-of-network provider if you are out of our service area, as long as the additional
care you get meets the definition of “urgently needed care” that is given below.
What is urgently needed care?
Urgently needed care refers to a non-emergency situation when you are:
- Inside the United States
- Temporarily absent from the Plan’s authorized service area
- In need of medical attention right away for an unforeseen illness, injury, or condition, and
- It is not reasonable given the situation for you to obtain medical care through the Plan’s participating provider network.
Under unusual and extraordinary circumstances, care may be considered urgently needed and paid for by our Plan when the member
is in the service area, but the provider network of the Plan is temporarily unavailable or inaccessible.
What is the difference between a “medical emergency” and “urgently needed care”?
The two main differences between urgently needed care and a medical emergency are in the danger to your health and your location.
A “medical emergency” occurs when you reasonably believe that your health is in serious danger, whether you are in or outside
of the service area. “Urgently needed care” is when you need medical help for an unforeseen illness, injury, or condition, but
your health is not in serious danger and you are generally outside of the service area.
How to get urgently needed care
If, while temporarily outside the Plan’s service area, you require urgently needed care, then you may get this care from any
provider. Note: If you have a pressing, non-emergency medical need while in the service area, you generally must obtain services
from the Plan according to its procedures and requirements as outlined earlier in this section.
How to submit a paper claim for emergency or urgently needed care
When you receive emergency or urgently needed health care services from a provider who is not part of our network, you are responsible
for paying your plan cost sharing amount and you should tell the provider to bill our Plan for the balance of the payment they
are due. However, if you have received a bill from the provider, please send that claim to: Essence Healthcare, P.O. Box 12488,
St. Louis, MO 63141, so we can pay the provider the amount they are owed. If you have any questions about what to pay a provider
or where to send a paper claim you may call Customer Service.