Emergency Situations Requiring Hospitalization
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Published: October, 2001
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PBH should be notified of any admission or impending admission
as soon as possible. PBH staff is available 24 hours a day
at our member line to discuss authorization for inpatient
admissions and to facilitate referral to a participating facility.
(See Quick
Reference Guide in the Region Specific Information section
of this manual for the member access number). If it is impossible
for a provider to obtain such authorization, an "emergency
condition" must be reasonably suspected for PBH to consider
reimbursement for that admission.
In some cases it may be impossible for the provider to contact
PBH due to imminent concerns about the safety of the member.
In such circumstances the provider should ensure the member's
safety or admit the member into a hospital. However, PBH should
be contacted as soon as possible or within 24 hours and provided
with a clinical update as well as the facility's phone number
and the name of the facility's representative. The provider
should also be prepared to assist in arranging transportation
for the member to a participating facility.
Emergency conditions, such as an overdose or lacerations
that require emergency medical treatment or clearance, are
the responsibility of the member's medical plan. A referral
for medical care must be arranged. Once the member is medically
stable, behavioral health problems can be addressed.
If it is determined that a member does not need the level
of care provided by a hospital, or that an alternate facility
would be more appropriate for his or her treatment, a PBH
Care manager will recommend a referral to an alternate program
or provider. The original admitting facility and attending
professional will be reimbursed for the authorized emergency
admission and medically necessary services rendered until
such transfer of the member can be arranged.
If it is determined by PBH that the admission did not meet
the definition of emergency as stated above, the facility
and attending provider may not be reimbursed.
Claims for services provided to a PBH member that do not
qualify as emergency services or urgently needed care and
that have not been pre-authorized by PBH may be denied. Emergency
services and urgently needed care for screening and stabilization,
without Pre-Authorization, are covered for cases where a prudent
layperson, acting reasonably, would have believed that an
urgent need or emergency existed.
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