Appropriate 911/emergency care procedures

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, 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 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 Member Services/Customer Service telephone number on the back of their Anthem ID card with any questions.

An 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 requires a health plan to provide coverage for emergency services to screen and stabilize a condition unless there is evidence to show that either the services were never performed or the member did not require emergency services and 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.

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