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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