CALIFORNIA - Pacificare Health Systems

Emergency Services – Prior Authorization
for treatment of Medical Emergencies is
not required.
What is an Emergency Medical Condition?
An Emergency Medical Condition is a
medical condition manifesting itself by acute
symptoms of sufficient severity (including
severe pain) such that a prudent layperson,
with an average knowledge of health and
medicine, could reasonably expect the
absence of immediate medical attention to
result in:
1. placing the member’s health in serious
jeopardy;
2. serious impairment to bodily functions;
3. serious dysfunction of any bodily organ or
part. In the case of a pregnant woman, an
Emergency Medical Condition exists if the
member is in Active Labor, meaning labor
at a time at which either of the following
would occur:
a. there is inadequate time to effect safe
transfer to another hospital prior to
delivery; or
b. a transfer may pose a threat to the
health and safety of the member or the
unborn child.
Emergency Services Are Covered Inpatient
or Outpatient Services That Are:
1. furnished by a Provider qualified to
furnish Emergency Services, and
2. needed to evaluate or stabilize a
Medical Emergency.
What To Do In An Emergency
In the event of a Medical Emergency, go
to the closest emergency room or call
911 for assistance. PacifiCare will cover
Emergency Services whether you are in or
out of the Service Area. Ambulance services
dispatched through 911 are only covered
if transportation in any other vehicle could
endanger your life. You need to have
someone telephone your Primary Care
Physician or PacifiCare at the number listed
Section 6 – Emergency and
Urgently Needed Services
on your Secure Horizons Group Retiree
Medicare Advantage Plan membership card
as soon as reasonably possible. The Secure
Horizons Group Retiree Medicare Advantage
Plan offers worldwide emergency coverage.
Emergency Services are covered whether or
not a Contracting Medical Provider provides
them. It is important to notify your Primary
Care Physician or PacifiCare of a Medical
Emergency so your Primary Care Physician or
PacifiCare can be involved in the management
of your health care. If the Medical Emergency
requires that you be admitted to an inpatient
Hospital, it is important that you notify your
Primary Care Physician or PacifiCare so that a
transfer can be arranged when your medical
condition is stable (as determined by your
treating Physician). Please contact your
Primary Care Physician or PacifiCare at the
number located on your membership card
within forty-eight (48) hours or as soon as
reasonably possible.
If you have a Medical Emergency while
outside of the Service Area, PacifiCare will
cover follow-up care outside of the Service
Area only when the follow-up care continues
to meet the definition of either Emergency
or Urgently Needed Care. You will be
responsible for the Emergency or Urgent
Care Copayment whether you receive the
Emergency or Urgently Needed Care services
from a Physician or a Specialist in a doctor’s
office or if you receive the Emergency or
Urgently Needed Care services in an Urgent
Care Facility or a Hospital. After treatment for
an out of the Service Area Medical Emergency,
follow-up care that does not continue to meet
the definition of either Emergency or Urgently
Needed Care must be received in the Service
Area from your Primary Care Physician. If you
receive out of the Service Area follow-up care
that does not meet the definition of either
Emergency or Urgently Needed Care, you may
be financially responsible for the cost of the
follow-up care.
If you have a Medical Emergency within the
Service Area, you should contact your Primary
Care Physician or Contracting Medical Group/
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B