Trauma services are medically necessary, covered services given at a state-licensed, designated trauma facility or a facility designated to receive trauma cases. Trauma services must meet identified county or state trauma criteria.
We may retrospectively review trauma service claims and medical records to verify that they met the trauma criteria. We may also confirm the trauma facility has an active trauma license.
We consider these criteria when authorizing trauma services:
- Trauma team activated.
- Trauma surgeon is the primary treating health care provider.
- Member’s clinical status meets the county’s current EMS protocols for designating a trauma member.
- Trauma services, once rendered, apply to the first 48 hours post-facility admission, unless there is documented evidence of medical necessity indicating that trauma level services are continuing delivery.
- Trauma service status should no longer apply when, based on medical necessity, the member is stable and/or medically appropriate for transfer out of the critical care area.
- Clinical management of a member(s) by the trauma team is not the sole criterion used to determine and authorize continued trauma services care.