PURPOSE

Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an . Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation.

Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

Coverage for emergency room services

Coverage for emergency room services is subject to the terms, conditions and limitations of the applicable benefit plan and may be impacted by state law.

Cigna reimburses emergency room services when a “prudent layperson” (a person who possesses an average knowledge of health and medicine) has an emergency medical condition presenting with acute or rapid onset of sufficient severity (including pain) that the “prudent layperson” would expect that the absence of immediate medical attention would result in ANY 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
• serious dysfunction of any bodily organ or part

Covered emergency room services do not require prior authorization or health care provider referral.

A005 Covered emergency room services from a non-participating provider or facility will be reimbursed at the in-network benefit plan level when the above criteria are met.

General Background

Generally, emergency room (department) services are provided when an individual has an acute injury, a sudden illness, or an existing illness that quickly becomes much worse and requires immediate medical attention.

Cigna's goal is to provide coverage for quality care in the most appropriate setting. Emergencies should be treated in the emergency room, and patients should get emergency care when they need it at the sudden onset of a serious injury or life-threatening illness.

No Cigna participant, regardless of benefit plan type, is required to get prior authorization before seeking treatment in an emergency room. In addition, if a participant's primary care provider refers him/her to the emergency room, regardless of the nature or severity of the illness or injury, the claim will be covered.

Definitions

Acute: Rapid or sudden onset of a condition that is a change from the individual’s normal condition and requires immediate medical care.

Prudent Layperson (PLP): One who possesses an average knowledge of health and medicine.

Emergency Medical Condition: A medical condition manifesting 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 that the absence of immediate medical attention to result in:

• 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
• serious dysfunction of any bodily organ or part

The prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms and their reasonable expectation that their symptoms could result in serious jeopardy, impairment, or dysfunction. It does not focus on the resulting diagnosis.

Examples of symptoms

Examples of symptoms that a prudent layperson might expect would result in a serious medical outcome without immediate medical attention include: severe chest pain or other potential signs of a heart attack, severe shortness of breath, rapid onset of heavy bleeding, severe trauma, or suicidal thoughts. However, symptoms that a prudent layperson might assume would not result in serious jeopardy include: common colds, immunizations, a follow-up doctor visit, mild pain, minor cuts and bruises, sprains and strains, and suture removal.