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Emergencies and urgent care, Oxford - 2021 Administrative Guide

Urgent Care

Urgent care is medical care for a condition that needs immediate attention to minimize severity and prevent complications but is not a medical emergency. It does not otherwise fall under the definition of emergency care.

Definition of a medical emergency

Connecticut: An “emergency condition” is defined as a medical condition, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine, acting reasonably, would have believed that the absence of immediate medical attention would result in placing the health of such person or others in serious jeopardy, or serious impairment to bodily functions; or serious dysfunction of a bodily organ or part; or would place the person’s health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

New Jersey: An “emergency condition” is defined as a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance use, and the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists where there is inadequate time to affect a safe transfer of the woman or unborn child to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child.

New York: “Emergency condition” means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

Emergency room visits

We cover ER services for medical emergencies. The member is responsible for paying their copayment. Follow-up ER visits within our service areas are not covered. However, follow-up care, if appropriate, is coordinated through the member’s PCP and is subject to the standard referral process.

  • ER visits during which a member is treated and released without admission do not require notice to us.
  • If an ambulatory surgery occurs because of an ER or urgent care visit, you must notify us within 24-48 hours of when the surgery is performed. Coordinate all follow-up needs related to such emergency services through the member’s PCP. They are subject to the standard referral process.
  • When a member is unstable and not capable of providing coverage information, the facility should submit the concurrent authorization as soon as they know the information and communicate the extenuating circumstances.

In-area emergency services

You do not need to provide notification or obtain authorization for in-area ER treatment and subsequent release. However, all emergency inpatient admissions and emergency outpatient admissions (i.e., for emergent ambulatory surgery) require notification upon admission or on the day of admission (no later than 48 hours from the date of admission, or as soon as reasonably possible).

Out-of-area emergency services

Out-of-area coverage for ER services are limited to care for accidental injury, unanticipated emergency illness or other emergency conditions when circumstances prevent a member from using ER services within our service area.

Emergency admission review

If the member is admitted to a hospital due to an emergency (as previously defined), we review the hospital admission for medical necessity and determine appropriate length of stay based on our approved criteria for concurrent review. Review begins when we become aware of the admission. You must notify us of all emergency inpatient admissions no later than 48 hours from the date of admission, or as soon as reasonably possible. If the member is admitted to a contracted hospital, we use reasonable efforts to transmit a decision about the admission to the hospital (to the fax number and contact person designated by the hospital) within 24 hours of making the decision.

Non-emergency hospitalization

Any hospitalization service that does not meet the criteria for an emergency or for urgent care requires prior authorization and is subject to medical necessity review.

Coverage outside of the United States

Oxford provides limited coverage for members outside of the United States, Mexico, Canada, or the U.S. Territories.

New York (NY) and Connecticut (CT) products

The following applies to out-of-country care providers.

  • Claims received for services performed outside of the United States do not require an authorization if the services are emergent in nature.
  • We will not cover elective procedures outside of the United States, Mexico, Canada or the U.S. Territories for members who reside in the United States unless an authorization exists specifically indicating that out-of-country services were authorized. This includes prenatal care and delivery.
  • All claims from out-of-country care providers must be translated and the amount billed and calculated in American dollars using the conversion rate as of the processing date.

New Jersey (NJ) products

The following applies to out-of-country care providers.

  • Claims received for services performed outside of the United States do not require an authorization if the services are emergent or urgent in nature.
  • Claims will not be covered for elective procedures outside of the United States, Mexico, Canada or the U.S. Territories for members who reside in the United States unless an authorization exists specifically indicating that out-of-country services were authorized. This includes prenatal care and delivery.
  • All claims from out-of-country care providers must be translated and the amount billed and calculated in American dollars using the conversion rate as of the processing date.

Out-of-country resident members

NJ Small Group/PPO FP and Liberty

Services provided outside of the United States are excluded unless the covered member is outside of the United States for one of the following reasons:

  • Travel, provided the travel is for a reason other than securing health care diagnosis and/or treatment, is for a period of 6 months or less.
  • Business assignment, provided the covered member is temporarily outside of the United States for a period of 6 months or less.
  • Eligibility for full-time student status (subject to pre- approval), provided the covered member is either enrolled and attending an accredited school in a foreign country or is participating in an academic program in a foreign country, for which the institution of higher learning at which the student matriculates in the United States grants academic credit.

Note: We deny charges in connection with full-time student status in a foreign country that we have not pre-approved as noncovered charges.