Emergent/Urgent Care

Whenever possible, a Commercial HMO or Medicare Advantage (HMO) member should first contact his or her Personal Care Physician (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 emergent medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in one of the following:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
• Serious impairment to bodily functions; or
• Serious dysfunction of any body organ or part.

For commercial HMO or Medicare Advantage (HMO) 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 under commercial HMO or Medicare Advantage (HMO) when a member is temporarily absent from the plans’ service area, or when the member is in the service area but the member’s health center 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.

Urgent Care Clinic

Providers who would like their clinic to be marketed as an “Urgent Care Clinic” and be recognized by HMSA as a Participating “Urgent Care Clinic” for the PPO line of business, the following additional criteria must be met:

• Be staffed by MD or DO.
• Provide services before or after normal business hours during the week.
• Maintain weekend operating hours.
• Accept unscheduled walk-in patients (adults and children).
• Provide lab and X-ray equipment and services on premises or nearby.
• Provide urgent medical care for an unexpected illness or injury that is not life-threatening, but cannot wait until the patient visits a personal care provider. These conditions include, but are not limited to:
  • Coughs, colds, sore throats
  • Fractures and sprains
  • Minor burns
  • Ear, nose and throat infections
  • Stomachaches
  • Headaches or dizziness
  • Allergic reactions
  • Animal bites

For questions or more information, please contact Provider Data & Contract Administration at provider_data@hmsa.com.

Revision History