NY Manual
SHP Manual

New York Provider Manual
10.10 Custodial-Long-Term-Care-Placement | 11.2 Urgent Care

11. EMERGENCY CARE

11.1 Emergent Care

Healthfirst members are covered for inpatient and outpatient emergency care services within the Healthfirst geographic service area and also when members are traveling in or visiting out-of-area locations. Emergency services are reimbursed when an emergency medical condition exists or when a Healthfirst provider instructs the member to seek emergency care either in- or out-of-network as is appropriate to the member’s situation. Services must be provided by facilities or healthcare professionals qualified to render emergency medical care.

***PRIOR AUTHORIZATION FROM HEALTHFIRST IS NEVER REQUIRED FOR REIMBURSEMENT OF AN EMERGENT MEDICAL CONDITION.

Definition of an Emergency Medical Condition

As set forth in Section 4900(3) of the New York State Public Health Law, an "emergency condition" means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, which a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

·     Placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such person or others in serious jeopardy
·     Serious impairment to such person’s bodily functions
·     Serious dysfunction of any bodily organ or part of such person
·     Serious disfigurement of such person

Emergency Guidelines

When a Healthfirst member presents in the emergency room for care, the hospital is responsible for providing medically necessary and appropriate treatment. The hospital must contact the PCP as soon as possible to obtain clinical information that may be necessary to provide appropriate treatment. If a member presents in the emergency room with a non-emergent condition, the hospital should contact the PCP and document that contact. The hospital is then responsible for deciding and carrying out the necessary and appropriate course of action. Referral to the PCP for non-emergency treatment may be arranged.

If the PCP is referring the member for emergency care, the PCP should send the member to his or her assigned hospital whenever possible or to the emergency room of the closest hospital. The PCP should contact the emergency room by telephone or fax to provide necessary medical information. Members should be instructed to return to the PCP’s office for follow-up, when appropriate, after an emergency room visit. If the member has received emergency care and the follow-up care cannot be safely postponed until the member returns, the member should be instructed to seek follow-up care from the appropriate out-of-area provider.

Emergency Inpatient Admissions

For emergency admissions, prior authorization is not required, but the treating facility or physician must contact Healthfirst within 48 hours of the admission or as soon as possible to ensure proper post-stabilization care and discharge planning.  Providers should contact Medical Management via the telephone and fax For emergency admissions, prior authorization is not required, but the treating facility or physician must contact Healthfirst within 48 hours of the admission or as soon as possible to ensure proper post-stabilization care and discharge planning.  Providers should contact Medical Management via the telephone and fax numbers listed in Section 1 or through the Healthfirst Information Exchange.

In addition, hospitals are responsible for contacting the member’s PCP to advise of the proposed admission and to obtain any relevant information regarding the member’s condition, past medical history, and other relevant information. Healthfirst PCPs who practice in private, community-based settings and do not have admitting privileges at Healthfirst hospitals (Level III providers) should contact their hospital liaison to arrange for admission to the appropriate participating hospital in emergency situations as well as in elective cases.

If a Healthfirst member is hospitalized for emergency care in a nonparticipating institution, Healthfirst will cover the cost of the emergency services and the cost of all medically necessary inpatient days until such time as the member may be safely transported to a participating facility. Healthfirst’s Medical Management staff will work with staff at both hospitals to arrange the transfer when it is judged to be safe by the member’s attending provider.