EMERGENCY LEVEL
Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting to participating professional providers and/or to participating facilities is based on diagnostic criteria, the definition of emergency, and all applicable facility provider and/or professional provider contract terms.
Emergency is defined as the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any one of the following:- The health of the individual being placed in serious jeopardy
- The health of a pregnant woman or her unborn child being placed in serious jeopardy
- Serious impairment to the individual's bodily functions
- Serious dysfunction of any of the individual's bodily organs or parts
Medical emergency situations include, but are not limited to:- Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions
- Accidents such as, but not limited to, falls, severe cuts, broken bones, and other traumatic bodily injuries
TRIAGE LEVEL
When the individual's condition does not meet diagnostic criteria or the definition of emergency, the participating facility and/or participating professional provider, in accordance with the applicable provider contract, may receive a reduced level of reimbursement. This reduced level of reimbursement is referred to as a triage rate or triage level of reimbursement.
