Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
of Oklahoma Emergent and Urgent Care Criteria General Guidelines: ! A decision to authorize or deny coverage for an emergency service is based on the patient’s presenting symptoms arising from any injury, illness or condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of medical attention to result in: a. serious jeopardy to the health of the patient; b. serious impairment to bodily function; or c. serious dysfunction of any bodily organ or part. ! Lack of notification to the plan is not criteria for denial of covered emergency services.. ! Patient screening, evaluating, and examination services that are reasonably calculated to assist the provider in determining whether the condition of the patient requires emergency service. If the provider determines that the patient does not require emergency service, payment for services rendered subsequent to that determination shall be governed by the HMO contract. ! If within a period of thirty (30) minutes after receiving a request from a hospital emergency department for a specialty consultation, a plan fails to identify an appropriate specialist who is available and willing to assume the care of the enrollee, the emergency department may arrange for emergency services by an appropriate specialist that are medically necessary to attain stabilization of an emergency medical condition, and the plan shall not deny coverage for the services due to lack of prior authorization; and ! The reimbursement policies and patient transfer requirements of a plan shall not, directly or indirectly, require a hospital emergency department or provider to violate the federal Emergency Medical Treatment and Active Labor Act. If a member of a plan is transferred from a hospital emergency department facility to another medical facility, the plan shall reimburse the transferring facility and provider for services provided to attain stabilization of the emergency medical condition of the member in accordance with the federal Emergency Medical Treatment and Active Labor Act. (Approved by the QI Committee 12/01) of Oklahoma In Area ER Criteria The following are recommendations for conditions which may require treatment in the ER setting. Abdominal or flank pain, acute (severe distress) Abdominal rigidity Nausea and vomiting Melena Ascites Acute appendicitis, pancreatitis, incarcerated hernia Alcohol withdrawal, with impending DT’s Anaphylaxis Arrhythmia, including tachycardia and bradycardia; heart rate <60 or >110 with symptoms of decompensation or malfunction, pacemaker. Asthma, severe acute episode Back pain, severe Bleeding / hemorrhage (vomitus, major wound, possible incomplete abortion, history of Coumadin use, hemophilia) Blindness sudden (glaucoma, retinal detachment, or any acute episode) Burns (2nd or 3rd degree major / chemical) Cardiac / Respiratory Arrest Cerebrovascular accident (CVA / Stroke / TIA) Chest Pain Choking Cold or pulseless extremity Coma or near coma Dehydration, severe, accompanied by an electrolyte imbalance Diabetic ketoacidosis / coma / insulin reaction Dislocation of joint Drug overdose/ reaction Eye injury / illness causing partial or complete loss of vision; penetrating foreign body Fracture, open or closed, with displacement / visible deformity (excluding toes) Gallbladder, acute attack Gastroenteritis, acute symptoms and onset Head trauma, recent with episodes of decreased level of consciousness, slurred speech, abnormal behavior, blurred vision, nausea, vomiting Headache, severe acute, associated with neurologic symptoms (Approved by the QI Committee 12/01) Heatstroke / Sunstroke (dehydration , fever, electrolyte imbalance) Hypertensive crisis (diastolic 110) Kidney stone, severe symptoms Loss of consciousness, fainting, syncope. Major trauma, blunt head, abdomen, chest; gunshot wound; penetrating head, abdominal, chest, or back wound; amputation; major eye trauma; spinal injury; MVA Mental status change, acute delirium (e.g., speech loss, uncontrollable hysteria, severe anxiety, panic attack, and disruptive violent behavior) Myocardial Infarction (actual or suspected) Obstetric complications; suspected miscarriage; acute swelling; headache/ abdominal pain; vaginal bleeding, with pregnancy and post-therapeutic abortion; postpartum bleeding; placenta previa; abruptio placenta; eclampsia; pre-eclampsia; ruptured ectopic pregnancy; hyperemesis Pain, severe Penetration / imbedded or ingested foreign body Pleurisy Pneumothorax, Pneumonia, Pneumonitis Poisoning, any type Pyelonephritis, Pyelitis, acute with pain or bleeding Renal dialysis patient with clotted shunt or infection Respiratory obstruction, distress, severe shortness of breath, flared nostrils, sternal retractions, tripod positioning air hunger, cyanosis Seizures, acute onset or status epilepticus Sexual assault Shock, Hypotension Sickle cell crisis Snake bite Suicide Attempt Urinary retention, acute Vomiting, severe, accompanied by electrolyte imbalance Weakness, acute unilateral Conditions listed below usually should allow for discussion with the PCP or on-call physician and direction by the physician to the appropriate level of care. Abdominal pain, non-acute Chronic with no changes Treated and seen without change Mild GI upset Abrasions/ bruises/ contusions Allergies or urticaria for more that 24 hours, non progressive Back pain, chronic (without re-injury) Burns, minor First degree burns Sunburns Cellulitis or abscess Chronic with no changes Cold / flu symptoms Earache, sore throat Epistaxis / nosebleed, uncontrolled Eye infections Eye injury: Superficial foreign body Corneal abrasion (Approved by the QI Committee 12/01) Fever - 103° temperature in children less than 3 years old 101° in infants less than 3 months of age Seizure activity Dehydration Fracture / dislocation, closed, with minimal deformity Jaundice Joint pain without trauma Lacerations Migraine Headaches Mild/ chronic headache Motor Vehicle Accidents, with delayed symptoms. Puncture wounds Rash Thrombophlebitis