BlueCross BlueShield of Tennessee Administrative Services

Emergency Care

DESCRIPTION

Emergency services include: medical services and medically necessary ancillary services furnished in the hospital emergency department that are required to evaluate, treat, and stabilize an individual's emergency condition, medical or accidental, as directed or ordered by a physician in accordance with hospital protocol.

Hospitals providing emergency care are required to provide an appropriate medical screening examination. Triage is not an equivalent of a medical screening examination. The decision to treat the individual is made by the examining physician(s) or other qualified medical person actually caring for the individual at the treating facility, not the managed care plan.

An emergency condition is defined by a "prudent layperson", who possesses an average knowledge of health and medicine, as a medical condition that develops itself by symptoms of sufficient severity, including severe pain. Failure to provide such treatment could reasonably be expected to result in:

POLICY

BlueCross BlueShield of Tennessee recognizes the need for access to emergency care. Emergency care is medically necessary if the individual has one or more of the attached medical diagnoses. (See Medical Appropriateness below.)

Treatment of a chronic condition in which subacute symptoms have existed over a period of time is not medically necessary for emergency care unless symptoms suddenly become severe enough to require immediate medical assistance regardless of the hour of the day or night.

MEDICAL APPROPRIATENESS

If the “principal” diagnosis (discharge/final diagnosis; CMS 1450 [UB-04] form locator 67) is not on the diagnosis list, then the “admitting” diagnosis (presenting symptoms; CMS 1450 form locator 69) must be considered when determining medical necessity of an emergency.

Please see the lists below for the diagnoses or set of symptoms that should be considered for medical emergency care:

SOURCES

American College of Emergency Physicians. (1996). Emergency care guidelines. Retrieved November 2, 2000 from http://www.acep.org/library/index.cfm/id/458.

Heimoff, S. (1999). Will prudent layperson please report to the ER. Managed Care, 8 (5), 43-46 & 49.

Tennessee Code 56-7-2355. (2000). Coverage of emergency services. Retrieved November 2, 2000 from  http://www.lexislawpublishing.com/sdCGI-BIN/om_isapi.dll?clientID=5836&infobase=tncode.NFO&jump=56-7-2355&softpage=Document#JUMPDEST_56-7-2355.

ORIGINAL EFFECTIVE DATE:   12/79

MOST RECENT REVIEW DATE:  3/12/2015

ID_THM

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.