Emergency Medical Condition - A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (1) placing the health of the person afflicted with such condition in serious jeopardy; or (2) Serious impairment to such person's bodily functions; or (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.
Emergency room services shall be covered accordingly, with the member responsible for the designated co-payment (if hospitalization occurs, there will be no emergency room co-payment). However, when emergency visits occur in non-emergency situations, the member may be liable for some charges.
BEHAVIORAL HEALTH CARE
Outpatient mental health care, when provided by a participating physician or provider, is for evaluative and short-term therapy or crisis intervention psychiatric care only. Psychotherapy for chronic conditions (i.e. chronic depression, schizophrenia), which, in the sole judgment of Atlantis Health Plan, are not subject to significant clinical improvement through short-term therapy, is not covered. Treatment for conditions such as attention deficit disorder and marital counseling are not covered.
Inpatient psychiatric care, including electroshock therapy for acute conditions when subject to significant improvement over a short-term, and when provided by a participating provider, is covered.
Inpatient detoxification services as a consequence of alcohol or substance dependency are covered in participating facilities. Rehabilitation services (in or outpatient) are covered to the extent provided for in the individual subscriber contract.
For pre-certification of Behavioral Health Care benefits please call our Behavioral Health Care Utilization Department at 800-469-5636