Medical Emergency
A medical emergency is the sudden onset of a medical condition, such as unusually severe symptoms. Immediate medical attention should be sought if the condition could result in serious jeopardy to the mental or physical health of the member, danger of serious impairment of the member’s bodily functions, serious dysfunction of any of the member’s bodily organs, or in the case of a pregnant woman, serious jeopardy to the health of the fetus.
Piedmont Community HealthCare acknowledges, supports, and pays for prudent emergency care. Members are covered for emergency care, as described below, anytime, anywhere in the world. Preauthorization is not required for a medical emergency. However, follow-up care for emergencies must be coordinated by the member’s PCP (if applicable) and appropriate authorization must be obtained prior to treatment.
If the services of a specialist are required, the member should make every effort to be treated by a participating specialty physician. Should a member seek emergency room services or require inpatient care, Piedmont Community HealthCare should be notified within 24 hours of admission or the next business day after a weekend or holiday to ensure proper claims processing. Please refer to your Certificate of Coverage for a more detailed description of emergency procedures.
Examples of a medical emergency are:
- Convulsions
- Loss of consciousness
- Obvious broken bones
- Prolonged or repeated seizures
- Serious Burns
- Severe or unusual bleeding
- Sudden onset of severe pain
- Suspected poisoning
- Trouble breathing
- Vaginal bleeding during pregnancy
Out-of-Area Coverage
A member is covered for emergency care or urgent care when traveling outside of the service area. Emergency services outside the service area will be covered if the member is out of the service area, or if the patient is a covered dependent who is a full-time student outside the service area.
All members are covered at the in-network level for true medical emergencies when traveling outside of the service area. Once stabilized, if additional care is needed, Piedmont Community HealthCare arranges for care to be provided within the service area.
If an Emergency or Urgent Care situation occurs when you are temporarily outside of the service area, you should obtain care at the nearest medical facility. You or your representative are responsible for notifying your Primary Care Physician (PCP) or Piedmont within 24 hours of admission or on the next business day after a weekend or holiday. Failure to do so may result in reduced benefits or no benefits. For specific terms and conditions please CLICK HERE.
Benefits for continuing or follow-up treatment must be pre-arranged by your Primary Care Physician or Piedmont and provided in the service area by Piedmont providers and are subject to all provisions of the member Certificate of Coverage.
