An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.
Examples of emergency illness or injury are:
„ Serious breathing difficulties
„ Unconsciousness
„ Uncontrollable bleeding
„ Sudden onset of chest pain
„ Major burns
„ Seizures
When you are in need of emergency care, go to the nearest emergency facility or call 911 or any available area emergency response service. If a delay would not be detrimental to your health, call your primary care physician (PCP). Your
PCP is required to provide emergency coverage
24 hours a day, including weekends and holidays.
Members who are traveling outside their health plan service area or students who are away at school are covered for emergency and urgently needed care.
An urgent medical condition is one for which care is medically necessary and immediately required because of unforeseen illness, injury, or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through the member’s home service area or from the PCP.
The following are considered urgent care outside your HMO service area :
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Severe vomiting
Earaches
Severe sore throat
High fever
When using emergency room facilities, you will have a copayment at the time of receiving services. The ER copay does not apply if you are admitted as an inpatient to the hospital.
If you are admitted to an inpatient facility, you or a family member or a friend on your behalf should notify your PCP and the health plan as soon as possible.
All follow-up care must be coordinated by your
PCP. Follow-up care with a non-participating provider is only covered with a referral from your PCP and pre-approval by your health plan medical group or IPA.
Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center or an emergency facility. Follow-up care must be coordinated through your PCP.
The urgent care facility or treating physician should try to contact your PCP to allow the physician to contribute to the treatment you require.
In other cases you should notify your PCP of the treatment as soon as possible.
If you or a family member utilizes the services of an emergency room or urgent care facility in a situation other than an urgent medical or lifethreatening emergency, charges for those services will become your financial responsibility.
Under the health plan, if you or a covered family member receives a bill for services directly from a provider, you should immediately send the bill to the claim address on the back of your I.D. Card. For identification purposes, please include your
Aetna I.D. Number on the bill. Always keep a copy for your records.
Additional information about Medical Emergencies and Urgent Care can be found in the “Covered Benefits” section of the Evidence of Coverage. In case of a conflict between your plan documents and this information, the plan documents will govern.
Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of
Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.
WR-020717 (07/02)