- Participating Physician Groups (PPG)
(does not apply to HSP)
Emergency care is covered for an emergency medical condition, which is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
- Placing the patient's health in serious jeopardy.
- Serious impairment to bodily functions.
- Serious dysfunction of any bodily organ or part.
Active labor is considered an emergency medical condition. Active labor means labor at the time that either of the following could reasonably be expected to occur: (1) there is inadequate time to effectively transfer safely to another hospital prior to delivery; or (2) a transfer poses a threat to the health and safety of the member or unborn child.
Emergency care includes:
- Medical screening, examination and evaluation by a physician (or other personnel to the extent permitted by applicable law and within the scope of his or her license and privileges) to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.
- Additional screening, examination and evaluation by a physician (or other personnel to the extent permitted by applicable law and within the scope of his or her license and privileges) to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, either within the capability of the facility or by transferring the member to a psychiatric unit within a general acute hospital or to an acute psychiatric hospital as medically necessary.
- Air and ground ambulance and ambulance transport services provided through the 911 emergency response system.
Health Net makes final decisions about emergency care.
Refer to definition of phychiatric emergency medical condition for more information.