Many employees are unsure how the Enhanced PPO plan covers emergency room visits

Many employees are unsure how the Enhanced PPO plan covers emergency room visits.

Emergencies (Dial 911)

Hospital charges for emergency room treatment of a life-threatening condition or an accident are covered at 100% after a $90 co-payment. There is no need to be concerned about the network status of the hospital in an emergency – the most important thing is to get care as quickly as possible. An emergency is the sudden onset of a medical condition that a reasonable person would consider an emergency. Emergencies are signaled by acute symptoms that could reasonably be expected to result in:

Serious jeopardy of the patient’s health	Self-inflicted harm to the patient
Serious impairment of bodily function	The patient harming others
Serious dysfunction of an organ or other body part

Non-Emergencies

If you go to the emergency room when your situation is a non-emergency, you will pay a $140 co-payment and then your care is covered at 80% (after the deductible) if you use a network hospital. If you use a non-network hospital, then your care is covered at 60% (after the $140 copay and the deductible). You are responsible for paying the copay, the deductible and remaining 20% or 40%.

By scheduling an appointment with a participating physician instead of using the emergency room for non-emergencies, you pay the just the $25 co-payment for the office visit instead of the deductible and remaining 20% or 40%.

If You’re Unsure Call Nurseline

Remember the Optum Nurseline is available 24 hours a day and can connect you to registered nurses who can answer your health care questions. Call toll-free at (888) 609-5880.

Emergency Room Claims Payments

Often, the hospital does not provide details of the emergency room visit. For example, if you go to the emergency room for chest pains, a prudent person would consider this a possible heart attack. If the emergency room doctor diagnosis heartburn, the hospital will report heartburn to the insurance company. The insurance company will then pay the claim at the non-emergency level. In order for the claim to be considered at the higher emergency level, you must call the insurance company and provide the additional details for the reason of your visit. This may require you to obtain the emergency room physician notes from the hospital and submit them to the insurance company for reconsideration of the claim.

Revised: July 29, 2015.