Emergency services are services provided in or out of the service area in connection with the initial treatment of a medical or psychiatric emergency and are available 24 hours a day and seven (7) days a week.

 

A member who considers a medical or psychiatric condition to be an emergency should be instructed to call 911 or go to the nearest hospital emergency room immediately. Anthem Blue Cross (Anthem) covers emergency services that are necessary to screen and stabilize a condition. No authorization or pre-certification is needed if the member reasonably believes that an emergency medical or psychiatric condition exists. A member should be directed to call the telephone number on the back of their Anthem ID card with any questions.

 

A medical emergency is an unexpected acute illness, injury, or medical or psychiatric condition that could endanger health if not treated immediately. Examples of medical/psychiatric emergencies include:

 

  • Severe pain
  • Chest pains
  • Heavy bleeding
  • Sudden weakness or numbness of the face, arm or leg on one side of the body
  • Difficulty breathing or shortness of breath
  • Sudden loss of consciousness 
  • Active labor 
  • Attempted suicide
  • Suicidal/homicidal ideation 
  • Acute psychosis
  • Hazardous drug reactions/interactions

 

California law prohibits health plans from denying payment for emergency services, even if the situation was discovered not to be emergent, unless the member did not require emergency services and care and the member reasonably should have known that an emergency did not exist. Answering machine instructions and after-hours answering service staff of all HMO and PPO practitioners must direct members to call 911 or go directly to the nearest emergency room if they reasonably believe they are experiencing an emergency.



Featured In:
December 2019 Anthem Blue Cross Provider News - California