Emergencies and Urgent Care

What is a medical emergency and what to do if you have one?

A "medical emergency" is when you, or any other reasonable person with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a body organ or part. Or in the case of a pregnant women in active labor, meaning labor at a time when there is not enough time to safely transfer you to another hospital before delivery, or the transfer may pose a threat to your health or safety or to that of your unborn child.

If you have a medical emergency:

  • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
  • As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours of the onset of the emergency. Please contact Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.

What is covered if you have a medical emergency?

You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories. Emergency care is not covered outside of the United States or its territories. The plan covers ambulance services in situations where you, or any other reasonable person with an average knowledge of health and medicine, believe getting to the emergency room in any other way could endanger your health.

If you have an emergency, the Plan or your PCP will talk with the doctors who are giving you emergency care to help manage and follow-up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over.

After the emergency is over, you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan, but we may need to pre-approve it. If an out- of-network provider provides your emergency care, the plan or your PCP will work with you as needed to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow.

What if it wasn’t a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it was not a medical emergency after all.

Examples of medical emergencies include:

  • Broken bones
  • Convulsions or seizures
  • Severe chest pain or heart attack
  • Serious accidents
  • Stroke (symptoms often include facial droop, speech difficulty)
  • Loss of consciousness
  • Heavy bleeding
  • Severe headaches or other pain
  • Vomiting blood or continuous vomiting
  • Fainting or dizzy spells
  • Poisoning
  • Shock (symptoms often include sweating, feeling thirsty, dizzy, pale skin)
  • Severe burns
  • Trouble breathing
  • Sudden inability to see, move, or speak
  • Suicidal thoughts, plans and/or actions
  • First experience of auditory or visual hallucinations

If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor has said that it was not an emergency, we will cover additional care only if you get the additional care in one of these two ways:

  • You go to a network provider to get the additional care.
  • The additional care you get is considered "urgently needed services" and you follow the rules for getting these services.

If you have any questions, contact Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.

What is a "behavioral health emergency"

A "behavioral health emergency" is an emergent situation in which someone is in need of behavioral health assessment and treatment in a safe and therapeutic setting, is a danger to themselves or others, or exhibits significant behavioral deterioration rendering the member unmanageable and unable to cooperate in treatment.

If you have a behavioral health emergency or mental health crisis:

  • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
  • If you are experiencing a mental health crisis, call 1-833-234-2264 24 hours a day, 365 days a year.

A mental health crisis is any situation in which a person's behaviors puts them at risk of hurting themselves or others, and/or when they are not able to resolve the situation with the skills and resources available. Many things can lead to a mental health crisis including, increased stress, physical illness, problems at work or at school, changes in family situations, trauma/violence in the community or substance use. These issues are difficult for everyone, but they can be especially hard for someone living with a mental illness.

As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Please contact Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.

What if you are in the plan's service area when you have an urgent care need after normal business hours?

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or a condition that requires immediate medical care to prevent a worsening of health due to symptoms that a reasonable person would believe are not an emergency but do require medical attention. You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable and it is not reasonable to wait to obtain care from a network provider, we will pay for the covered service(s) provided to you.

You can walk into an urgent care clinic to get care the same day or make an appointment for the next day. Whether you are at home or away, call your primary care provider (PCP) any time, day or night. If you cannot reach your PCP, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730). Tell the person who answers what is happening. They will help you find care.

You can also call the Behavioral Health Crisis Line at 1-833-234-2264, at any time, 24 hours a day, 7 days a week.

If you are in danger or need immediate medical attention, call 911.