Emergency care

No matter where you are, if you have a medical emergency — that is, a sudden and unexpected change in your physical or mental condition which, if not treated immediately, could result in a loss of life or limb, significant impairment of a bodily function or permanent dysfunction of a body part — you should go to the nearest emergency room to get the care you need.

Emergency medical condition

An emergency medical condition is a recent and severe medical condition, including (but not limited to) severe pain, which would lead a prudent person possessing an average knowledge of medicine and health, to believe that his or her condition, illness or injury is of such a nature that failure to get immediate medical care could result in:

  • Placing your health in serious jeopardy; or
  • Serious impairment to bodily function; or
  • Serious dysfunction of a body part or organ; or
  • In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Examples of medical emergencies include heart attack, stroke, severe bleeding, serious burns and poisoning. It can sometimes be difficult to determine when urgent situations are true emergencies. If you need help determining whether your situation is a true emergency, you can consult a doctor who will be able to tell you what steps to take. You can also contact Aetna's 24-Hour NurseLine at 1-800-556-1555 to speak with a registered nurse.

Emergency services

“Emergency services” means, with respect to an emergency medical condition:

  • A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and
  • Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital to stabilize the patient.
Under all PPO Options, you receive the higher, network level benefits for emergency services — even if you see an out-of-network provider. You do not need prior authorization for the treatment of an emergency medical condition, even if the services are provided by an out-of-network provider. Care provided by an out-of-network provider will be paid at no greater cost to you than if the services were performed by a network provider. You may receive a bill for the difference between the amount billed by the out-of-network provider and the amount paid by Aetna. If an out-of-network provider bills you directly for an amount beyond your cost share for the treatment of an emergency medical condition, you are not responsible for paying that amount. Please send the bill to the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over the amount. Make sure your member ID number is on the bill.

Under all OOA Options, your cost may be lower if you use Aetna's National Advantage Program (NAP). See Aetna's National Advantage Program (NAP) for more information. You do not need prior authorization for the treatment of an emergency medical condition.

Under both the PPO and OOA Options, if you are admitted to the hospital, you or someone on your behalf is required to certify your hospitalization within 48 hours (or two business days) of your emergency admission. Instructions on how to contact your claims administrator are provided on your medical option ID card.

 

Publication date: April 2019

 

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