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MA PAP208

Emergency and Urgent Services


Provider Administrative Policy

Section
Provider Information
Policy Date
July 2007
Status/Date
Reviewed/June 2011

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Emergency and Urgent Services

 Emergency services

We do not require prior authorization for emergency medical treatment . Blue Cross of Idaho Medicare Advantage plans cover emergency services whether the member is in or out of their plan's  service area. We define emergency services as covered inpatient or outpatient services that are:

  • Furnished by a provider qualified to furnish emergency services.
  • Needed to evaluate or stabilize an emergency medical condition.

An emergency medical condition is one with acute symptoms severe enough (including severe pain)  that a prudent layperson with an average knowledge of health and medicine could reasonably expect the lack 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.

Urgently needed care within the plan's service area:
Urgently needed  care is care needed immediately for an unforeseen illness or injury that is not unreasonable, given the situation, to receive medical care from the member`s primary care physician (PCP) or other plan providers. In this case, the member`s health is not in serious danger. If the member has a sudden illness or injury that is not a medical emergency and the member is in the plan`s service area, the member should call his or her PCP.

Urgently needed care outside the plan's service area:
When members are outside the plan's service area, Medicare Advantage covers urgently needed care provided by non-participating providers.  Whenever possible, members should first contact their PCP for urgent care when they are outside the plan's service area. Members should also receive follow-up care from their PCP for any treatment received outside the service area.  When a member receives care that meets the definition of urgently needed care from non-participating providers outside the plan service, we cover claims for any needed follow-up care.

Effective January 1, 2011, when one of the following is present on a claim, it will be identified as an urgently needed care claim.

  • Place of Service 20:  When billing for urgently needed care services on a CMS-1500, urgently needed care is determined by the place of service 20 (urgent care) regardless of the diagnosis billed for the E & M code.
  • Revenue Code 516:  For rural health clinics or other UB04 billing, urgently needed care is determined by revenue code 516

Policy History

Date Action Reason
June 2011 Revised Place of Service/Revenue code clarification

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