CurrentHealth NetPolicy N/A

Emergency services notification and hospital admission reporting

Governs definition of emergency medical condition and requirements for hospitals and participating physician groups to notify Health Net's Hospital Notification Unit for member admissions; applies to Health Net members and participating providers in North Carolina.

Policy Summary

PayerHealth Net

PolicyEmergency services notification and hospital admission reporting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionTreating ED must complete and send the hospital face sheet to Health Net Hospital Notification Unit for admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-995-7890HNU phone (all products)

800-676-7969Employer group fax

844-760-8992IFP fax

24 hrs / 1 business dayContact timeframe

Emergency Services Coverage & Notification

Emergency services coverage and notification requirements

Covered when the emergency medical condition and administrative notification requirements below are met:

Emergency medical condition is present as defined by acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate medical attention to result in serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; includes considerations for pregnant women and the unborn child.

Emergency services are those inpatient or outpatient services furnished by a provider qualified to provide emergency services and needed to evaluate or treat an emergency medical condition.

Hospital notification: For hospital admissions of a Health Net member, the treating emergency department of a participating hospital must complete and send the hospital face sheet to Health Net's Hospital Notification Unit (HNU).

HNU timing and methods:

Policy Summary

PayerHealth Net

PolicyEmergency services notification and hospital admission reporting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionTreating ED must complete and send the hospital face sheet to Health Net Hospital Notification Unit for admissions.

SourceLink

On This Page

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Hospital & Physician Group Notification Requirements

Documentation Required

Admission notification and PPG authorization

The treating emergency department of a participating hospital must complete and send the hospital face sheet to Health Net's Hospital Notification Unit (HNU) for hospital admissions. Participating physician groups (PPGs) must notify the Health Net Medical Management Department and provide the PPG authorization number when treatment has been authorized.

Hospitals: complete and send hospital face sheet to HNU for admissions.
PPGs: notify Health Net Medical Management and supply PPG authorization number if treatment authorized.

Key Definitions

inv-03: Emergency medical condition — definition of emergency medical condition for policy scope

DefinitionAn emergency medical condition: acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health (or, for a pregnant woman, the health of the woman or her unborn child), serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

Prudent layperson standardAssessment is based on what a prudent layperson with average health/medical knowledge would reasonably expect if immediate care were not provided.

Scope — pregnant womenIncludes conditions that would jeopardize the health of a pregnant woman or her unborn child.

Severity examplesSpecifically notes severe pain and other acute symptoms as qualifying features.

inv-04: Emergency services — definition of emergency services covered by the policy

DefinitionEmergency services are covered inpatient and outpatient services that are (1) furnished by a provider qualified to provide emergency services and (2) needed to evaluate or treat an emergency medical condition.

Care settingsApplies to both inpatient and outpatient services when provided to evaluate or treat an emergency medical condition.

Provider qualificationServices must be furnished by a provider qualified to provide emergency services.

PurposeLimited to services needed to evaluate or treat the emergency medical condition (not broader elective care).