5.22.15d – (LAA) Out of Network Changes

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May 22, 2015

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LAA
Out of Network Change – Effective June 1, 2015 – health@apfa.org
We have had numerous member inquiries about how a hospital emergency visit is processed if one of the treating Doctor’s is “out-of network” (such as an anesthesiologists) at an in-network hospital?
 
The AA plan will consider out-of network providers such as anesthesiologists as “in-network” as long as the facility itself is in-network. The AA plan will also consider an out-of network emergency care as “in-network” as long as it is a true emergency.
 
How Does AA Define a True Emergency? 
UHC and BCBSTX have a similar way of defining a true emergency. Blue Cross defines a  true emergency by a specific set of diagnosis codes that are deemed to be “accident & emergency.” UHC uses the following criteria when adjudicating claims:

A True Emergency is defined as a serious medical condition or symptom resulting from injury, sickness or mental illness, or substance use disorders which arisess suddenly, and in the judgment of a reasonable person requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health such as:

• Serious jeopardy to one’s health, including the health of a pregnant woman  or her unborn child;
• Serious impairment of bodily functions; and/or
• Serious dysfunction of any bodily organs or body parts.