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| Last Updated: January 12,
2005 |
Urgent and Emergency Care Coverage
Be prepared for urgent and emergency situations
We encourage you to prepare for injuries and illnesses before
they happen. Taking some time to learn our urgent and emergency
care procedures can help you get the care you need quickly and
ensure that your treatment will be covered.
Hospital care must be approved in advance, except in the case
of an emergency. Note that most medical conditions are not emergencies
and can be treated at your doctor's office or at a non-emergency
facility.
Determining the type of care you need
There are three general categories of medical conditions or
care:
Preventive/routine: Preventive and routine care is
for conditions that generally do not need immediate attention.
This care may lead to prevention or early detection and treatment
of conditions. Examples of preventive and routine care include
immunizations, screenings and physical exams.
Urgent: Urgent medical conditions are those requiring
prompt attention. These injuries or illnesses are not life-threatening
and waiting for care will not cause a significant risk to the
patient. Such conditions might include minor sprains, cuts
and burns.
Emergency: Emergency medical conditions are those where
a "prudent layperson" (which is the legal term for
a reasonable person who does not have medical know-how) believes
that if the sick or injured person does not receive immediate
medical attention, it would seriously jeopardize his or her
health or seriously impair bodily functions. Examples of emergency
conditions include broken bones, convulsions, severe burns,
poisoning, chest pains or bleeding that will not stop. For
a complete definition of what is a true emergency, please see
your Subscriber Certificate.
What to do if you have an urgent care condition
Urgent care facilities are designed to treat urgent needs relatively
quickly, and they are also generally much less expensive. Emergency
rooms first treat the patients whose conditions are the most
serious, so your wait could be very long there. If your condition
is urgent but not an emergency, you must:
 Search
for an urgent care facility
What to do if you have an emergency condition
If you have a suddenly occurring emergency condition or injury,
you should get medical care immediately. In the event of an emergency
situation, please do the following:
- Call your primary care physician before getting emergency
care or within 48 hours
- Go to a Care Choices HMO facility when you are in the Care
Choices HMO service area - unless transit time to that facility
would place your health in serious jeopardy - or call 911
Your primary care physician will arrange all follow-up care
for urgent and emergency conditions with Care Choices participating
providers. In all other situations, you must call your primary
care physician before you get medical care.
When you are out of town
Remember, when you are out of town, Care Choices HMO only covers
treatment for emergency conditions.
- Remember to take your primary care physician's phone number
with you.
- If you are out of town and have an urgent condition, please
remember to call your primary care physician before you receive
care.
- If you are out of town and have an emergency condition, get
help immediately and ask the facility to send the bill to Care
Choices HMO at the address listed on the back of your Member
ID Card.
If the facility asks you to pay the bill when you receive treatment,
do so. When you return home, send your itemized receipt to Member
Services for reimbursement. If your condition was an emergency
condition, Care Choices HMO will pay for your care less any copayment.
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