Subject:
Definition of Medical Emergency
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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"Emergency" means a medical or psychiatric condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; serious dysfunction of a bodily organ or part; or the possibility of jeopardy to others. The symptoms may include, but are not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse.
For the purposes of applying this policy, a "prudent layperson" is considered to be a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether emergency medical or psychiatric treatment is needed. A prudent layperson will be considered to have acted "reasonably" if other similar situated laypersons would have believed, on the basis of observation of the medical or psychiatric symptoms at hand, that emergency treatment was necessary.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Medical Emergency services are eligible only when:
A. rendered by a physician or appropriate allied health care professional acting within his or her scope of licensure.
B. the condition shows itself in sudden and unexpected symptoms of sufficient severity that the absence of immediate medical attention is reasonably expected to result in:
- an immediate or delayed threat to life, limb or an organ; or
- permanent impairment to an organ or body part.
C. the condition is treated immediately after the onset and while the symptoms are present. These symptoms may include, but are not limited to:
- uncontrolled bleeding
- airway obstruction
- loss of consciousness
- crushing chest pain
Accidental injuries considered as medical emergencies may include, but are not limited to:
- bone fractures
- burns
- poisoning
- wounds requiring sutures
- penetrating wounds
Examples of symptoms that are generally not considered an emergency include, but are not limited to, the following:
- fever, swollen glands, rashes
- headache, cold, toothache
- minor pains or discomfort
- vomiting, cramps, intermittent abdominal pain
2. Determination of coverage must be made based on whether a prudent layperson, acting reasonably, would have believed that an emergency medical or psychiatric condition existed.
Medicare Coverage:
Medicare Advantage Products are included in Horizon BCBSNJ Medical Policy: Definition of Medical Emergency (Introduction 005).
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Definition of Medical Emergency
Medical Emergency, Definition of
References:
Balanced Budget Act (BBA) of 1997. Section 4704. Available at http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/html/PLAW-105publ33.htm
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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