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Medi-Cal Member Handbook / Benefit Year 2006-2007Emergency Care: How do I getcare in an emergency?There is a difference between needing careurgently and an emergency. Urgent care is when acondition, illness or injury is not life-threatening,but needs medical care right away. Many ofCommunity Health Plan’s doctors have urgentcare hours in the evening and on weekends.How to get urgent care1. Call your PCP doctor. You may speak toan operator who answers calls for yourPCP doctor’s office when closed.2. Ask to speak to your PCP doctor or thedoctor on-call. Another doctor may answeryour call if your PCP doctor is notavailable. A doctor is available by phone24 hours a day, seven days a week.3. Tell them about your condition and followtheir instructions.If you are outside of Los Angeles County, you donot need to call your PCP doctor or get priorauthorization before getting urgent care services.Be sure to let your PCP doctor know about thiscare. You may need follow-up care from yourPCP doctor.What is emergency care?Emergency services are covered anywhere 24hours a day, seven days a week. Emergency careis a service a “prudent layperson” believes isnecessary to stop or relieve:• Serious illnesses or symptoms• Injury or conditions requiring immediatediagnosis and treatmentA “prudent layperson” is a non-medical personwith an average knowledge of health and medicinebut has awareness or information to make agood decision.Emergency services and care include ambulance,medical screening, exam and evaluation by adoctor or appropriate personnel. Emergencyservices include both physical and psychiatricemergency conditions.Examples of emergencies include but are notlimited to:• Having trouble breathing• Seizures (convulsions)• Lots of bleeding• Unconsciousness/blackouts (will not wake up)• Trouble breathing• In a lot of pain (including chest pain)• Swallowing of poison or medicine overdose• Broken bones• Head injury• Eye injury• Thoughts or actions about hurting yourself orsomeone elseIf you think you have a health emergency, call911. You are not required to call your doctorbefore you go to the emergency room. Do notuse the emergency room for routine healthcare.What to do in an emergencyCall 911 or go to the nearest emergency roomif you have an emergency. Emergency care iscovered at all times and in all places.25Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
Medi-Cal Member Handbook / Benefit Year 2006-2007Outside of Los Angeles County?If you have an emergency when you are not inLos Angeles County, you can get emergencyservices at the nearest emergency facility (doctor’soffice, clinic or hospital). Emergencyservices do not require a referral or an okay fromyour PCP doctor.limited to, the following: earaches, colds, flu andsore throats. Do not call 911 for non-emergencyproblems. Call your PCP doctor.If you are admitted to a hospital not inCommunity Health Plan’s network or to a hospitalyour PCP doctor or other provider does notwork at, Community Health Plan has the right tomove you to a network hospital as soon asmedically safe.Your PCP doctor must provide follow-up carewhen you leave the hospital.What to do after an emergency1. Call Community Health Plan within 24hours of receiving emergency care or assoon as you can.2. Follow the instructions of the emergencyroom doctor.3. Call your PCP doctor to make an appointmentfor follow-up care.How to get emergency transportationCall 911 if you have an emergency. Ambulancesfor emergencies are paid for by CommunityHealth Plan. Community Health Plan may refuseto pay if you use an ambulance when you do nothave a reasonable belief that you have an emergency.Not sure you have an emergency?If you are not sure, call your PCP doctor. Dowhat your PCP doctor tells you to do. Nonemergencyproblems may include, but not be26Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
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