Does Emergency Services require Authorization ?

Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably
expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

*  Serious jeopardy to the health of the member, including a pregnant woman or fetus
*  Serious impairment to bodily functions
*  Serious dysfunction of any bodily organ or part
*  A pregnant woman having contractions

SHP shall not:
*  Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;
*  Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.
*  Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;
*  Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or
*  Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.
*  Deny claims for emergency services and care received at a hospital due to lack of parental consent.

Pre-hospital and hospital-based trauma services and emergency services and care will be authorized.

SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless
authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the
existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

If the hospital is unable to notify SHP, the hospital must document its attempts to notify the Plan, or the circumstances that precluded the hospital's attempts to notify the Plan. SHP shall not deny coverage for emergency services and care based on a hospital's failure to comply with the notification requirements of this section.

SHP shall cover any medically necessary duration of stay in a non-contracted facility, which results from a medical emergency, until the Plan can safely transport the member to a participating facility. SHP may transfer the member, in accordance with state and federal law, to a
participating hospital that has the capability to treat the member’s emergency medical condition. The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer, and that determination is binding.

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