May 22, 2015
We have had numerous member inquiries about how a hospital emergency visit is processed if one of the treating Doctor’s is "out-of network" (such as an anesthesiologists) at an in-network hospital?
The AA plan will consider out-of network providers such as anesthesiologists as “in-network” as long as the facility itself is in-network. The AA plan will also consider an out-of network emergency care as “in-network” as long as it is a true emergency.
How Does AA Define a True Emergency?
UHC and BCBSTX have a similar way of defining a true emergency. Blue Cross defines a true emergency by a specific set of diagnosis codes that are deemed to be "accident & emergency." UHC uses the following criteria when adjudicating claims:
A True Emergency is defined as a serious medical condition or symptom resulting from injury, sickness or mental illness, or substance use disorders which arisess suddenly, and in the judgment of a reasonable person requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health such as:
- Serious jeopardy to one’s health, including the health of a pregnant woman or her unborn child;
- Serious impairment of bodily functions; and/or
- Serious dysfunction of any bodily organs or body parts.