Emergency Services
Emergency services are not subject to prior authorization requirements and are
available to our members 24 hours a day, seven days a week, 365 days a year.
An emergency medical condition is a medical condition manifesting itself by
acute symptoms of sufficient severity, which may include severe pain or other
acute symptoms, such that a prudent lay person who possesses an average
knowledge of health and medicine could reasonably expect that the absence of
immediate medical attention could reasonably be expect to result in any of the
following:
Serious jeopardy to the health of the
member, including a pregnant woman or fetus
Serious impairment to bodily functions
Serious dysfunction of any bodily organ
or part
A pregnant woman having contractions
SHP shall not:
Require prior authorization for an
enrollee to receive pre-hospital transport or treatment or for emergency services and care;
Deny payment for treatment obtained when
a representative of the SHP instructs the enrollee to seek emergency services.
Specify or imply that emergency services
and care are covered by the Plan only if secured within a certain period of
time;
Use terms such as "life
threatening" or "bona fide" to qualify the kind of emergency
that is covered; or
Deny payment based on a failure by the
enrollee or the hospital to notify SHP before, or within a certain period of
time after, emergency services and care were given.
Deny claims for emergency services and
care received at a hospital due to lack of parental consent.
SHP shall cover all screenings, evaluations, and examinations that are
reasonably calculated to assist the provider in arriving at the determination
as to whether the member has an emergency medical condition. If the provider
determines that an emergency medical condition does not exist, SHP is not
required to cover services rendered subsequent to the provider's determination
unless authorized by the Plan.
If the provider determines that an emergency medical condition exists, and the
enrollee notifies the hospital or the hospital emergency personnel otherwise
have knowledge that the patient is an enrollee of SHP, the hospital must make a
reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan
has previously requested in writing that it be notified directly of the
existence of the emergency medical condition
If the hospital, or any of its affiliated providers, do not know the enrollee's
PCP, or have been unable to contact the PCP, the hospital must notify SHP as
soon as possible before discharging the enrollee from the emergency care area;
or notify the Plan within twenty four (24) hours or on the next business day
after the enrollee’s inpatient admission.
If the hospital is unable to notify SHP, the hospital must document its
attempts to notify the Plan, or the circumstances that precluded the hospital's
attempts to notify the Plan. SHP shall not deny coverage for emergency services
and care based on a hospital's failure to comply with the notification
requirements of this section.
SHP shall cover any medically necessary duration of stay in a non-contracted
facility, which results from a medical emergency, until the Plan can safely
transport the member to a participating facility. SHP may transfer the member,
in accordance with state and federal law, to a participating hospital that has
the capability to treat the member’s emergency medical condition. The attending
emergency physician, or the provider actually treating the member, is
responsible for determining when the member is sufficiently stabilized for
transfer, and that determination is binding.
Emergencies at Out-of-State Hospitals
Emergency services provided in out-of-state hospitals are reimbursable when an
emergency arises from an accident or illness, the health of the recipient would
be endangered if the care or services were postponed until he returned to
Florida or if the health of the recipient would be endangered if he undertook
travel to return to Florida.
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