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Overview

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals

Emergency care is covered for acute illness, new injuries or an unforeseen deterioration or complication of an existing illness, injury or condition already known to the person or that a reasonable person with an average knowledge of health and medicine would seek if he or she was having serious symptoms (including symptoms of severe mental illness and serious emotional disturbances of a child), and believes that without immediate treatment, any of the following would occur:

  • His or her health would be put in serious danger (and in the case of a pregnant woman, would put the health of her unborn child in serious danger)
  • His or her bodily functions, organs or parts would become seriously impaired
  • His or her bodily organs or parts would seriously dysfunction

Emergency care also includes:

  • Treatment of severe pain or active labor. Active labor means labor at the time that either of the following would occur:
    • There is inadequate time to effectively transfer safely to another hospital prior to delivery
    • A transfer poses a threat to the health and safety of the covered person or unborn child
  • Ambulance and ambulance transport services provided through the 911 emergency response system, if the request was made for emergency care
  • Additional screening, examination and evaluation by a physician (or other health care provider acting within the scope of his or her license) to determine if a psychiatric emergency medical condition exists, and the care and treatment are necessary to relieve or eliminate such condition, within the capability of the facility
  • Treatment of shortness of breath and/or bleeding

Health Net makes final determinations about emergency care.

Last Updated: 10/30/2019