Limits: Aetna will reimburse member for reasonable cost as determined by Aetna by non-participating providers without prior written referral only if:

1. the service rendered is provided as a benefit under this certificate, and
2. The PCP is notified within 48 hours or by the end of the first business day following the emergency service. Aetna must be furnished with written proof of the occurrence, nature and extent of the emergency within 30 days of the date of services. Failure to immediately notify or to furnish written proof within 30 days will not invalidate or reduce any claim for reimbursement if Aetna determines that the member’s failure to do so was reasonable under the circumstances. However, no reimbursement shall be made until Aetna receives proper written proof.

Aetna may limit reimbursement for emergency services by a non-participating provider to expenses incurred up to the time the member is determined to be medically able to travel or to be transported to a participating provider.

Cost Sharing: Member is responsible for a copayment for each emergency visit to a physician’s office or hospital outpatient department or emergency room. The copayment for an emergency room visit will not apply if the member was referred by his/her PCP for services that should have been provided in the PCP’s office.

• Emergency services within medical service area. Go immediately to nearest hospital emergency room for treatment or call your PCP or 24 hour nurse call center for advice. BCBS will pay for screening and treatment to stabilize your condition. Any follow-up care must be provided by your PCP.
• Emergencies outside service area: Follow same procedure as you would within the service area. Members must pay a copayment for emergency services unless admitted to the hospital. BCBS will not pay for follow-up care rendered outside of the service area unless the member cannot return to the service area because of medical reasons. You must request coverage for continuing and follow-up treatment from your PCP in order for it to be approved.

Notification requirements: No authorization is required for maternity admissions for a stay of 48 hours for vaginal delivery or 96 hours for cesarean section. Approval must be requested if the member needs additional days. In other situations when the member is admitted to the hospital following an emergency, the member should contact BCBS as soon as possible to obtain approval for continued care.

Limits:

• If you are unsure whether your condition is emergent, call your PCP or the 24 hour nurse line for direction on your care.
• If you live outside of the service area, you will be covered for immediate treatment of an emergency. Follow-up treatment must be arranged in advance by your PCP.

Cost Sharing: Members must pay a copayment for emergency services unless admitted to the hospital.

Excludes: Non-emergency use of the emergency room. If BCBS decides the condition did not require emergency care, you will be responsible for all charges unless you obtained preauthorization from BCBS.

• Emergency services within service area. If members believe that an emergency exists, they should proceed to the nearest emergency care facility or dial 911 as appropriate. In an emergency, members are not required to obtain preauthorization, notify CHCNC that emergency services will be or have been utilized, or use in-plan facilities
• Emergency services outside service area. Healthsource will cover emergency care when medically necessary for members. Coverage includes students away at school, and members on vacation.
• For all emergency services: Care received in an emergency room must meet CHCNC’s emergency definition. Healthsource applies the prudent lay person language to its definition of an emergency. CHCNC will provide coverage for emergency services until the condition is stabilized. If the member is admitted, the emergency room copayment will be waived. Follow-up care is covered if provided by a member’s PCP or a Consulting Specialist, with referral from a PCP and prior authorization.
• Follow-up services only covered if provided by PCP, or upon referral of PCP and authorization by CHCNC.

Notification Requirements: After an emergency condition is stabilized, member must notify CHCNC of continued treatment. Notify your PCP as soon as reasonably possible, considering the member’s medical condition. If notification is not received, the services may not be covered.

Excludes: CHCNC will not cover emergency services which could have been foreseen before leaving the immediate area, including, but not limited to, delivery beyond 35^th week of pregnancy, dialysis, scheduled medical treatment, or therapy or upon physician recommendation that the member should not travel due to their medical condition.

• Emergency services within the service area: Members should proceed to the nearest emergency care facility or dial 911. Members will not be required to obtain pre-authorization or use in-plan facilities in order to receive coverage for emergency services.
• Outside Service Area: Same as above, including for students at school and members on vacation. However, routine care and follow-up care must be provided by student’s PCP.

Limits: Follow-up care is covered only if provided by the PCP or by a specialist if referred from a PCP and authorized by Doctors.

Cost Sharing: Copayments may apply.

Notification requirements: Members should notify Doctors of an emergency hospital admission as soon as reasonably possible to ensure payment of medical services.

Excludes: Non-emergency use of emergency room or services which are not medically necessary.

• Emergency services within medical service area: Call 911 or go immediately to nearest hospital emergency room. If you have any medically--related questions, you can call a Generations nurse triage/advice line at any time
• Emergency services outside service area: Follow same procedure as you would within the Service Area.

Notification requirements: None. Members are advised to notify their PCP and/or Generations as soon as possible after receiving services.

Cost Sharing: Copayments apply. The Emergency Room copayment will be waived if the emergency results in a hospitalization.

Excludes: Non-emergency use of the emergency room. If Generations determines that your condition does not meet the definition of an emergency, you will be responsible for all charges.

• Participating provider: Covers medical services from a participating provider needed to treat an emergency until the condition is stabilized. You do not need prior authorization to obtain emergency services.

• Non-participating providers: Covers emergency services from non-participating providers and facilities if the delay caused by being taken to a participating provider could reasonably be expected to cause the member’s health to worsen.

Notification Requirements: You should call OCCI to let them know about the emergency services you are receiving. OCCI may not be required to cover the medical services if you fail to notify OCCI about your emergency services.

Cost Sharing: Copayments apply. The copayment will be waived if immediately admitted to the hospital.

Excludes: If you seek care in the emergency room for a condition that was determined not to be a medical emergency and was not authorized by your PCP, you will be responsible for payment of the emergency room and any associated bills.

• Emergency services within service area: Needed to screen and stabilize the member. Members are encouraged to call their PCP if experiencing an emergency medical condition. If member cannot contact PCP, member should go to the nearest participating emergency facility.
• Emergency services in non-participating facilities: to be used only if a prudent lay person believed use of a participating facility would cause a delay that would worsen the member’s condition or because of circumstances beyond the member’s control. Resulting hospitalizations at non-participating facilities are covered until the member can be safely transferred.
• Emergency services outside service area: Covered only if the member could not reasonably have anticipated the need for care before leaving the service area, or if the delay in going to a participating provider would prove hazardous to the member’s health or life. Covers dependents living outside service area as full-time student for services necessary to stabilize and treat acute medical conditions resulting from emergencies and requiring immediate attention.

Notification Requirements: The member should notify the PCP or plan as soon as possible following emergency services. Follow-up care must be provided or arranged by PCP. Follow-up care will not be authorized unless member notifies PCP or plan within a reasonable time after receipt of emergency care.

Excludes: Emergency care outside the service area that could have been anticipated, such as maternity and delivery care.

Covers:

• Within Plan Service Area —Services for medical emergencies are covered for reasonable charges at hospitals within the Plan Service Area.

• Outside Plan Service Area: Coventry/Principal will cover emergency services provided by an out-of-area emergency room or physician. Your PCP will normally perform follow-up services. Payment is limited to treatment required before the member can safely return to the service area for necessary follow-up. Ground ambulance transportation to return member to a Coventry/Principal participating provider is covered when pre-authorized.

Notification Requirements: You must notify Coventry/Principal about your medical emergency within 48 hours to ensure coverage of services. If you are unable to because of a medical condition, notification requirements shall be waived. If you seek care in the emergency room for a condition that is not determined to be a medical emergency, you will be responsible for payment of the emergency room and any associated bills.

Notification: If, after you are stabilized, you are admitted through the emergency room, call Qual Choice to inform them of your condition and the services you are receiving.

Cost Sharing: Members are required to pay a set amount for each emergency room visit unless admitted to the hospital through the emergency room.

Note: Evidence of Coverage does not outline separate requirements for seeking emergency care within the service plan area compared to seeking care outside of the plan service area.

• Emergency services within medical service area. If members believe that an emergency exists, they should proceed to the nearest emergency care facility or dial 911 as appropriate. TWP-NC will pay for screening and treatment to stabilize your condition. You do not need prior authorization to seek emergency services.
• Emergencies outside service area: Follow the same procedure as you would within the service area. If possible, members should make every effort to obtain care in a participating hospital. TWP-NC will not pay for follow-up care rendered outside of the service area unless the member cannot return to the service area because of medical reasons.

Notification requirements: After an emergency condition is stabilized, the member must notify TWP-NC of continued treatment. Notify your PCP as soon as reasonably possible, considering the member’s medical condition. A delay may result in denial of coverage for the services.

Cost Sharing: Copay applies, which will be waived if admitted to hospital.

Non-participating facilities: Covers emergency services from non-participating providers and facilities if the member reasonably believed that the delay caused by being taken to a participating provider or hospital would worsen the emergency. Also covers emergency services from non-participating providers and facilities circumstances are beyond a member’s control. UHC may request that the hospitalized person be transferred to a participating facility as soon as it is medically appropriate. If the member declines to be transferred, he or she will be responsible for all future charges related to that admission. UHC pays nonparticipating hospital reasonable and customary charges for eligible health services. Therefore 100% of charges may not be covered. Members will be responsible for any charges above the reasonable and customary charge.

Cost Sharing: Copayments apply to all hospital admissions. If the member is admitted within 24 hours of emergency room treatment for the same illness, the inpatient hospital benefits will apply instead of the emergency room copayment. If the member receives outpatient surgical services for the same illness within 24 hours, outpatient surgery benefits will apply instead of the emergency copayment.

Medications: Prescriptions may be filled at a participating pharmacy but the member must pay for this prescription and submit the receipt to United HealthCare of North Carolina for reimbursement. Pharmacy benefits are not covered under all UHC plans. Coverage and the copayment depend on the purchased prescription drug benefit.

Notification Requirements: To ensure coverage, notify United HealthCare as soon as possible to coordinate medical care with PCP. Continuing or follow-up treatment after an emergency room visit must be provided by a participating physician. Continued care provided by a non-participating provider must be approved in writing and in advance by UHC.

Excludes: Non-emergency care provided in the emergency room.

Nonparticipating facilities: Member must be transferred to the care for a participating provider as soon as this can be done without harming the member’s condition.

Notice Request: The member (or someone acting for the member) should contact their PCP as soon as possible after seeking emergency care so that the PCP can coordinate follow up care for the member.

Limits: Condition must require emergency care.

Cost Sharing: Copayment applies, but will be waived if admitted to the hospital.