Emergency Room Services - Behavioral Health

HMSA plans cover the use of an emergency room when a member, acting as a prudent layperson, could reasonably expect the absence of immediate medical attention to result in:

• Serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child)
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part

Examples of Appropriate Use

Examples of a behavioral health emergency for which the use of an emergency room is appropriate include the following:

• Suicide attempt or intent to harm self
• Homicidal ideation resulting from mental illness
• Inability to function because of confusion or difficulty in thinking
• New or recent onset of hallucinations
• Extreme shakiness after ceasing to drink alcohol or ceasing the use of prescription medications (e.g., benzodiazepines or barbiturates)
• New or recent onset of fearfulness or paranoia
• Extreme anxiety (e.g., shortness of breath, rapid heart rate, shakiness) where the member believes he or she is having a heart attack or other life-threatening medical event
• Severe, acute exacerbation of a chronic mental condition

Examples of Inappropriate Use

The emergency room should not be used:

• To refill medications
• When the patient has no place to stay
• When the patient cannot sleep
• For non-life-threatening reasons (e.g., the patient needs to talk to someone, but cannot reach his or her usual behavioral healthcare provider)

Revision History