Peach State Provider Office Manual - Peach State Health Plan ...

EMERGENCY DEPARTMENT HOSPITAL CLAIMS ADJUDICATION PROCESSPurposeThis process describes the methodology to be used by Peach State for managing the EmergencyServices benefit in compliance with directives from Centers for Medicare and Medicaid Services(CMS) and the applicable State Agencies. This process delineates only adjudication ofEmergency Department claims. Peach State intends to work with physicians and hospitals todecrease the need for Emergency Services through proactive strategies that address chronicconditions such as asthma and to redirect, the member to their primary care provider (PCP). Inaddition, Peach State provides Emergency Department (ED) post-discharge follow up andcontinuity of care services.Peach State is dedicated to providing its members with high-quality healthcare. This includesimmediate access to Emergency Services when required. At the same time, Peach Staterecognizes that it is not in the member’s best interests to receive routine (non-emergent) episodiccare in the ED and that members are best served by receiving such care from their PCP’s.BackgroundThe federal Balanced Budget Act (BBA) of 1997 and the Medicaid statute have established thedefinition of “Emergency Medical Condition (EMC)” as follows:A medical condition manifesting itself by acute symptoms of sufficient severity (includingsevere pain) such that a prudent layperson, who possesses an average knowledge ofhealth and medicine, could reasonably expect the absence of immediate medicalattention to result in:• Placing the health of the individual (or, with respect to a pregnant woman, the health ofthe woman or her unborn child) in serious jeopardy;• Serious impairment of bodily functions; or• Serious dysfunction of any body organ or part.The contract agreement between Peach State and the Georgia Department of Community Healthcontains essentially the same definition of an EMC as in the federal statute. It states:Emergency Medical Condition: A medical condition manifesting itself by acutesymptoms of sufficient severity (including severe pain), such that a prudent layperson,who possesses an average knowledge of health and medicine could reasonably expectthe absence of immediate medical attention to result in placing the health of the individual(or, with respect to a pregnant woman, the health of the woman or her unborn child) inserious jeopardy, serious impairments of bodily functions, or serious dysfunction of anybodily organ or part. An Emergency Medical Condition shall not be defined on the basisof lists of diagnoses or symptoms.The agreement further delineates that an EMC is a medical or mental health conditionmanifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudentlayperson, who possesses an average knowledge of health and medicine, could reasonablyexpect the absence of immediate medical attention to result in the following:• Placing the physical or mental health of the individual (or, with respect to a pregnantwoman, the health of the woman or her unborn child) in serious jeopardy;• Serious impairment to bodily functions• Serious dysfunction of any bodily organ or part88Provider Services1-866-874-063302/22/2011