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Coverage Explanation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

Emergency services are covered under this plan when they are provided in the United States, Canada or Mexico. Members can reach Health Net 24 hours a day to speak with a nurse, through the McKesson nurse advice line. Providers may contact the Medi-Cal Provider Services Department or CalViva Health Medi-Cal Provider Services Center (for Fresno, Kings and Madera counties) with questions.

If a medical emergency occurs, members should be directed to the nearest emergency room for care or call 911. Members are encouraged to use the 911 emergency response system as appropriate. Members should notify their primary care physician (PCP) as soon as possible. Emergency services are available 24 hours a day, 7 days a week.

If a member goes to the emergency room and the doctor or nurse tells the member to contact his or her PCP because the members does not need emergency care, he or she should call his or her doctor immediately for direction.

Emergency Department Medical Screening Exam

A medical screening exam (MSE) is an initial assessment of a member to determine whether an emergency condition exists and whether the member should be treated in the emergency department or may be safely treated at another level of care. Hospital emergency departments are required to evaluate all members seeking care. An MSE performed by a physician, nurse practitioner (NP), registered nurse (RN), or physician assistant (PA) in an emergency department does not require prior authorization regardless of the outcome.

Physicians Authority for Discharge

All members are discharged from an emergency facility only on the order of a treating physician.

Timely Follow-Up Care

If the medical staff at the hospital emergency department determines that an emergency exists, they must render medical treatment until the condition is stabilized. Then, the hospital must receive authorization for further care through the PCP or on-call designee.

If the medical staff at the hospital emergency department determines that the condition is not an emergency, the member is responsible for arranging follow-up care with the PCP. Members are ordinarily given written instructions in the emergency department that state whether follow-up care is needed and, if so, how soon they need to be seen by their PCP. A sample instruction letter, Medi-Cal Member Instructions for Post-Emergency Care (PDF), is available for use. Emergency departments should also contact the member's PCP to arrange for follow-up care; particularly in circumstances where there are active or ongoing care needs or care coordination issues. PCPs must provide timely follow-up care to members when emergency care is deemed not necessary in an emergency department after an MSE or if follow-up care is indicated after treatment in the emergency department. PCPs should see members within the time frame suggested by the hospital emergency department instructions.

After-Care Instructions

Emergency departments are responsible for providing written post-emergency care instructions to all members seen in an emergency room. Refer to the Emergency Department MSE discussion above for the most current information about post-emergency care instructions and timely follow-up care.

Refer to definition of an emergency for more information.

Last Updated: 09/21/2022