Page 60 - Aegion PPO SPDs
P. 60
Outpatient Services
Outpatient Services include both Facility and professional charges when rendered as an Outpatient at
a Hospital, alternative care Facility; these Facilities may include a non-hospital site providing diagnostic and
therapy services, surgery, rehabilitation, or other Provider as determined by the Plan. Outpatient Services
do not include care that is related to Maternity or Mental Health/Substance Abuse Services, except as
otherwise specified. Professional charges only include services billed by a Physician or other professional.
Emergency Care and Urgent Care Services
For Emergency Accident or Medical Care refer to the Emergency Care and Urgent Care Services
section.
Emergency Care (including Emergency Room Services)
Life-threatening Medical Emergency or Serious Accidental Injury.
Coverage is provided for Hospital emergency room care including a medical screening examination that is
within the capability of the emergency department of a Hospital, including ancillary services routinely
available to the emergency department to evaluate an Emergency Medical Condition; and within the
capabilities of the staff and Facilities available at the Hospital, such further medical examination and
treatment as are required to Stabilize the patient. Emergency Service care does not require any prior
authorization from the Plan.
Stabilize means, with respect to an Emergency Medical Condition: to provide such medical treatment of the
condition as may be necessary to assure, within reasonable medical probability, that no material
deterioration of the condition is likely to result from or occur during the transfer of the individual from a
Facility. With respect to a pregnant woman who is having contractions, the term “stabilize” also means to
deliver (including the placenta), if there is inadequate time to affect a safe transfer to another hospital before
delivery or transfer may pose a threat to the health or safety of the woman or the unborn child.
The Maximum Allowed Amount for emergency care from a Non-Network Provider will be:
The amount negotiated with Network Providers for the Emergency service furnished;
The amount for the Emergency Service calculated using the same method the Claims Administrator
generally uses to determine payments for Non-Network services but substituting the Network cost-
sharing provisions for the Non-Network cost-sharing provisions; or
The amount that would be paid under Medicare for the Emergency Service.
The Coinsurance percentage payable for both Network and Out-of-Network are shown in the Schedule of
Benefits.
Urgent Care Center Services
Often an urgent rather than an Emergency medical problem exists. Urgent Care services can be obtained
from a Network or Non-Network Provider. If You experience an accidental injury or a medical problem, the
Claims Administrator will determine whether Your injury or condition is an Urgent Care or Emergency Care
situation for coverage purposes, based on Your diagnosis and symptoms.
An Urgent Care medical problem is an unexpected episode of illness or an injury requiring treatment which
cannot reasonably be postponed for regularly scheduled care. It is not considered an Emergency. Urgent
Care medical problems include, but are not limited to, ear ache, sore throat, and fever (not above 104
degrees). Treatment of an Urgent Care medical problem is not life threatening and does not require use of
an Emergency room at a Hospital. If You call Your Physician prior to receiving care for an urgent medical
problem and Your Physician authorizes You to go to an Emergency room, Your care will be paid at the level
specified in the Schedule of Benefits for Emergency Room Services.
See Your Schedule of Benefits for benefit limitations.
60
Outpatient Services include both Facility and professional charges when rendered as an Outpatient at
a Hospital, alternative care Facility; these Facilities may include a non-hospital site providing diagnostic and
therapy services, surgery, rehabilitation, or other Provider as determined by the Plan. Outpatient Services
do not include care that is related to Maternity or Mental Health/Substance Abuse Services, except as
otherwise specified. Professional charges only include services billed by a Physician or other professional.
Emergency Care and Urgent Care Services
For Emergency Accident or Medical Care refer to the Emergency Care and Urgent Care Services
section.
Emergency Care (including Emergency Room Services)
Life-threatening Medical Emergency or Serious Accidental Injury.
Coverage is provided for Hospital emergency room care including a medical screening examination that is
within the capability of the emergency department of a Hospital, including ancillary services routinely
available to the emergency department to evaluate an Emergency Medical Condition; and within the
capabilities of the staff and Facilities available at the Hospital, such further medical examination and
treatment as are required to Stabilize the patient. Emergency Service care does not require any prior
authorization from the Plan.
Stabilize means, with respect to an Emergency Medical Condition: to provide such medical treatment of the
condition as may be necessary to assure, within reasonable medical probability, that no material
deterioration of the condition is likely to result from or occur during the transfer of the individual from a
Facility. With respect to a pregnant woman who is having contractions, the term “stabilize” also means to
deliver (including the placenta), if there is inadequate time to affect a safe transfer to another hospital before
delivery or transfer may pose a threat to the health or safety of the woman or the unborn child.
The Maximum Allowed Amount for emergency care from a Non-Network Provider will be:
The amount negotiated with Network Providers for the Emergency service furnished;
The amount for the Emergency Service calculated using the same method the Claims Administrator
generally uses to determine payments for Non-Network services but substituting the Network cost-
sharing provisions for the Non-Network cost-sharing provisions; or
The amount that would be paid under Medicare for the Emergency Service.
The Coinsurance percentage payable for both Network and Out-of-Network are shown in the Schedule of
Benefits.
Urgent Care Center Services
Often an urgent rather than an Emergency medical problem exists. Urgent Care services can be obtained
from a Network or Non-Network Provider. If You experience an accidental injury or a medical problem, the
Claims Administrator will determine whether Your injury or condition is an Urgent Care or Emergency Care
situation for coverage purposes, based on Your diagnosis and symptoms.
An Urgent Care medical problem is an unexpected episode of illness or an injury requiring treatment which
cannot reasonably be postponed for regularly scheduled care. It is not considered an Emergency. Urgent
Care medical problems include, but are not limited to, ear ache, sore throat, and fever (not above 104
degrees). Treatment of an Urgent Care medical problem is not life threatening and does not require use of
an Emergency room at a Hospital. If You call Your Physician prior to receiving care for an urgent medical
problem and Your Physician authorizes You to go to an Emergency room, Your care will be paid at the level
specified in the Schedule of Benefits for Emergency Room Services.
See Your Schedule of Benefits for benefit limitations.
60
