QUEST Integration – Emergent/Urgent Care

Original Effective Date:

08/01/2008

Current Effective Date:

01/01/2015

Whenever possible, a QUEST Integration member should first contact his or her Primary Care Provider (PCP) for instructions regarding where to go for emergent/urgent care. For after-hours emergent/urgent care, the member can usually contact his or her PCP through a service such as Physicians Exchange. If the situation warrants, the member can be directed to the nearest emergency or urgent care facility for services. If the member is unable to contact his or her PCP prior to seeking medical attention, the member should contact his or her PCP within 48 hours or as soon as reasonably possible. This allows the PCP to arrange for a transfer when the member's condition is stable and provide follow-up care as necessary.

Emergent Care

An emergency medical condition is a condition manifesting itself by acute symptoms of sufficient severity (including 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 the following:

• Placing the physical or mental health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any body organ or part;
• Serious harm to self or others due to an alcohol or drug abuse emergency;
• Injury to self or bodily harm to others; or
• With respect to a pregnant woman having contractions: (1) that there is NOT adequate time to effect a safe transfer to another hospital before delivery, or (2) that transfer may pose a threat to the health or safety of the woman or her unborn child.

Emergency Medical Services are any covered inpatient and outpatient services furnished by a qualified provider and needed to evaluate or stabilize an emergency medical condition.

For QUEST Integration plan members, emergent care rendered by an emergency room (ER) practitioner in an outpatient ER facility does not require a referral or precertification.

Urgent Care

Urgent care is defined as services that require urgent attention and cannot reasonably be postponed. Urgent care is covered when a member is within Hawaii and temporarily absent from their service area (i.e., hometown, home city, and/or island of residence) or when the member is in the service area but the member’s health center and/or PCP is temporarily unavailable or inaccessible. Examples of urgent care include the following:

• The member’s condition is a result of an unforeseen illness, injury or condition that is not life-threatening but for which care cannot reasonably be postponed; and
• It is not reasonable, given the circumstances, to obtain the services through the member’s health center.

Revision History