Emergency Services means medically necessary health services that are immediately required for unforeseen illness or injury. Emergency Services for life or limb-threatening emergencies are available within our Plan at all times.
EMERGENCY TELEPHONE LINE
24 HOURS A DAY - 7 DAYS A WEEK
(303) 861-3434 (303) 831-6725 (TDD)
When you call the emergency number, we may tell you to go directly to the emergency room of a designated hospital or to our nearest facility. If an ambulance is medically necessary, we will authorize it. For
you should seek care immediately and, if possible, at one of the facilities listed below:
Kaiser Permanente Emergency Department
Saint Joseph Hospital Outpatient Entrance
18th Avenue and Humboldt Street
Denver, CO 80218
Swedish Medical Center
501 East Hampden Avenue
Englewood, CO 80110
Boulder Community Hospital
1100 Balsam Avenue
Boulder, CO 80302
Emergency Services that Medical Group Physicians provide, arrange or authorize in advance, including ambulance service, are covered. If you are not sure that your situation is an emergency,
and talk to our emergency nurse specialists. In the event of a life or limb-threatening emergency, you may
"Out-of-Plan Emergency Services" are Emergency Services that are not provided or authorized in advance by a Medical Group Physician. There may be times when you or a family member receive Emergency Services from non-Plan providers. The patient's medical condition may be so critical that you cannot call or come to one of our Medical Offices or the emergency room of a designated hospital. Or, the patient may need Emergency Services while traveling outside our Service Area.
If the patient is hospitalized for Out-of-Plan Emergency Services, you should notify us immediately or, in any event, within 48 hours after admission to the hospital. If the patient receives outpatient Emergency Services outside the Service Area, you should notify us within 48 hours by calling the emergency number given above or by calling your Medical Office directly. Appropriate arrangements then can be made for any necessary continued hospitalization, or for the patient's transfer to care within our Plan.
Coverage of Out-of-Plan Emergency Services is described in the following section. This coverage is
include unauthorized continuing or follow-up care outside of our Plan.
What Is Covered
Payment is limited to Emergency Services required before you can, without medically harmful consequences, be transferred to a designated Hospital or Medical Office inside the Service Area, or if you are near another Kaiser Permanente Region, be transferred to a contracting hospital or medical office in the other Region.
This means that Health Plan will NOT pay for Emergency Services received from non-Plan providers if your condition would have permitted you to travel to a designated Hospital or Kaiser Permanente's Emergency department located at Saint Joseph Hospital for your emergency care. Remember that if you are near one of our Medical Offices when you experience an emergency, you may seek care there during regular office hours.
Inside the Service Area:
We cover Out-of-Plan Emergency Services received inside the Service Area (See page 3 for description of the Service Area) only if the delay caused by taking the time to call us or coming to one of our Medical Offices or local designated hospitals would result in risk of death, services disability, or significant deterioration of your condition.
If you receive emergency services inside the Service area from non-Plan facilities or providers, an Emergency Service charge will apply to such services. (See your Benefit Chart.) If you are subsequently hospitalized, or if Health Plan personnel direct you to use non-Plan facilitates, the charge will be waived.
Outside the Service Area:
We cover Out-of-Plan Emergency Services if you are injured or become ill while outside the Service Area. Maternity services provided for an unexpected, premature delivery are covered. Delivery within 31 days of your expected due date is not considered premature. Services for normal deliveries are not covered.
This benefit is limited to Emergency Services required before your medical condition permits your travel or transfer to a local designated hospital or to a contracting hospital in the nearest other Kaiser Foundation Health Plan Region. Continuing or follow up care from Out-of-Plan providers is
covered, unless we decide not to transfer you to a Plan hospital. The cost of medically necessary special transportation to a Plan hospital is covered if we approve it in advance. As noted on page 10, no Plan benefits (including Emergency Services) apply to injuries arising from the negligence of third persons, nor do Plan benefits apply to that portion of medical, rehabilitation and hospital expenses for injury, illness or disease arising out of a motor vehicle accident which is covered under "no fault" motor vehicle insurance, unless this exclusion of coverage is specifically waived, in whole or in part. (See page 10 for more details.)
Health Plan's payment for covered Out-of-Plan Emergency Services is based upon charges that we determine to be reasonable. Our payment is reduced by: (1) an Emergency Service charge for services received in the Service Area from Out-of-Plan providers or facilities (See your Benefit Chart); (2) any other payments you would have had to make if you received the same services within our Plan; and (3) all amounts paid or payable, or which in the absence of your Service Agreement would be payable, for the Emergency Services in question, under any insurance policy or contract, or any other contract, or any government program except Medicaid.
Notification of Hospital Admission
If you receive services at a non-Plan hospital and a non-Plan physician suggests that you require admission, you or the admitting physician should notify us before you are admitted. In most cases we will be able to arrange a transfer to one of our Plan Hospitals. If you are medically able to be transferred, but do not notify us and instead are admitted to a non-Plan hospital, it is unlikely that we will pay or reimburse you for the cost of the care provided by the non-Plan hospital. In any event, you
notify us within 48 hours of any non-Plan hospital admission for which you will be seeking reimbursement or payment.
Notification can be made by you, your family, a friend, or the treating physician or hospital by calling one of the following numbers:
for the Patient Transfer Coordinator, or
TDD. Out of Colorado, call collect. In Colorado (Toll Free)
Monday-Friday 7:30 AM to 5:00 PM; Saturday 8:00 AM to 12:00 Noon.
Care for medical problems that do not meet the definition of an emergency because they are not sudden or unforeseen or do not require immediate treatment can be provided at our Medical Offices during regular office hours. Non-emergency care inside the Service Area is NOT COVERED at any non-Plan medical facility. If you receive care for minor medical problems at non-Plan facilities inside the Service Area, you will be responsible for paying for any medical treatment received.