Managed Care Program

Emergency Care

“True” emergency care does not require primary care provider (PCP) referrals. Managed Care beneficiaries may access “true” emergency care from clinics, physicians, nurse practitioners, physician assistants, after-hours clinics and hospital emergency rooms.

The Medical Assistance Program utilizes the Prudent Layperson definition for the determination of an “emergency medical condition”. The determination of whether the Prudent Layperson standard has been met must be focused on the presenting symptoms (and not on the final diagnosis), and must take into account the decision to seek emergency care was made by a prudent layperson (rather than a medical professional).

Prudent Layperson Emergency Definition

An “emergency medical condition”: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
  
• Serious impairment to bodily functions; or
  
• Serious dysfunction of any bodily organ or part.

Qualified medical personnel must determine whether the individual requires emergency care. An emergency condition determination must be documented and the information forwarded to the facility’s billing and coding personnel for proper billing of the service. Routine care for minor illness and injury is usually considered not to be a “true emergency” service.

If the examining provider determines, after study, an actual emergency medical condition does not exist, the Prudent Layperson standard must be followed. The determining factor for an emergency condition should be whether the beneficiary had acute symptoms of sufficient severity to have warranted emergency attention at the time of presentation.

Billing Emergency Care

• Physician and clinic services:
  CMS 1500 – enter “Y” or "N" in box 24C.
  
• Hospital:
  UB04 – enter “1” in box 14.
• Referrals:
  Emergency condition determination is not required when a beneficiary's PCP instructs* the beneficiary to seek emergency care.
• Verification of referrals is required:
  In the absence of written authorization, referrals may consist of a telephone confirmation between the attending provider and the PCP or his/her covering provider. Telephone confirmations must be documented.