NY Manual
SHP Manual

New York Provider Manual
11.1 Emergent Care | 12.1 Program Overview

11.2 Urgent Care

Definition of Urgent Medical Condition

Urgent medical conditions are defined as those illnesses and injuries of a less serious nature than emergencies but that require services to prevent a serious deterioration of a member’s health which cannot be delayed without imposing undue risk to the member’s well-being, or until the member either returns to the Healthfirst service area or until the member can secure services from his or her regular provider.

If the member is within the Healthfirst geographic service area and an urgent medical situation arises, he or she should contact the PCP for to obtain care on an urgent basis. The PCP may have the member seen in his or her office or may refer the member for treatment of an urgent, but non-emergent condition in an Urgent Care Center. If the PCP refers the member to a nonparticipating urgent care center or provider, an authorization from Healthfirst is required. The PCP should document this contact with the member as well as the recommended course of action in the member’s medical record. If the member is out-of-area at the time urgent care services are required, the PCP should be contacted as soon as possible for direction, but the member should seek appropriate care in the immediate location.

Medically necessary emergency services and medical care for stabilizing or evaluating an emergency condition are not subject to prior authorization. If a member believes that a medical emergency exists, he/she should go the nearest emergency room or call 911 for assistance.