Utilization Management Policy for Emergency Services and Emergent Worldwide Coverage
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Policy governing utilization management, coverage, and payment responsibilities for emergency medical and post‑stabilization services for Astiva Health members, including worldwide emergency reimbursement rules. Affects providers, Health Plan/MSO/IPA, and enrolled members.
No material clinical or coverage changes in this revision.
Emergency Services and Post‑Stabilization Coverage
Emergency Services and Post‑Stabilization Coverage
Covered when ALL of the following are met:
Monetary exchange rate fees, translation costs, postage, return travel to the U.S., and other nonmedical fees are not reimbursable for emergency care received outside the United States. Reimbursement for worldwide emergency and urgent care is limited to $50,000 per year after a $75 copayment; the copayment is waived if the member is admitted as an inpatient or placed under observation within 48 hours for the same condition. Members are responsible for paying providers upfront when treated outside the U.S. and must submit a discharge summary or equivalent medical documentation and proof of payment in English and U.S. dollars for reimbursement. If documentation or invoices are not in English or U.S. dollars, members must provide a certified translation and reimbursement will be calculated using the exchange rate at the time the check is processed; payments are made in U.S. dollars only.
Provider Requirements and Prior Authorization
No prior authorization for emergency services
Authorization is not required prior to the provision of emergency services and care that is necessary to stabilize the enrollee's emergency medical condition; emergency services shall not be subject to prior authorization.
Post‑stabilization prior authorization timeframe
If the ED provider contacts the Health Plan/IPA for post‑stabilization inpatient authorization, the Health Plan/IPA must approve or deny the request within 60 minutes; failure to respond within the timeframe deems the request approved.
- Decision to deny is made by the physician on call after receiving the full clinical report from the ER attending physician.
- If no response within 60 minutes, the authorization request is deemed approved.
No step therapy delay for life‑threatening emergencies
Delivery of care for life‑threatening or disabling emergencies must not be delayed for the purpose of determining eligibility or obtaining prior authorization.
Worldwide emergency documentation required for reimbursement
For reimbursement of emergency care received outside the U.S., the member must submit a discharge summary or equivalent medical documentation and proof of payment in English and U.S. dollars; non‑English clinical notes require a certified translation.
- Member pays upfront for services rendered outside the U.S.; reimbursement reviewed for medical necessity before payment.
- Reimbursement up to $50,000 per year after a $75 copayment (copay waived if admitted inpatient/observation within 48 hours).
Post‑stabilization denial pathway
If the Health Plan/IPA denies a post‑stabilization inpatient authorization request, the denial decision is made by the plan physician after receiving the full clinical report from the ER attending physician; if the Plan/IPA does not respond or a plan physician is not available, post‑stabilization services are deemed approved until consultation occurs.
- Treating physician may continue care until a plan physician is available to consult.
- Plan maintains physician coverage 24/7 to consult or resolve disputed authorization requests.
Key Definitions
Background
An emergency medical condition is a sudden onset of acute symptoms (including severe pain) of sufficient severity that absence of immediate medical attention could result in serious jeopardy to health, loss of life, limb, or bodily function. Emergency care comprises services furnished by a qualified provider necessary to evaluate or stabilize such a condition and is judged by a prudent layperson standard.
Astiva Health covers services necessary to evaluate or stabilize an emergency medical condition regardless of provider contract status; prior authorization is not required for these emergency services. When an enrollee is stabilized but continues to require medically necessary care, the servicing provider must notify the Health Plan or MSO/IPA within 24 hours during the stabilization period.
If the ED provider requests post‑stabilization inpatient authorization, the Health Plan/IPA must approve or deny the request within 60 minutes; failure to respond within this timeframe deems the request approved. If a denial is issued, the plan physician will make the final decision after receiving the full clinical report from the emergency attending physician.
For emergencies occurring outside the U.S., members must pay upfront and submit required documentation (discharge summary or equivalent and proof of payment) in English and U.S. dollars for reimbursement consideration. Nonmedical expenses such as exchange rate fees, translation costs, postage, and return travel are excluded from reimbursement.
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