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hmo managed care medicare

Lydia Posted Wed 06th of May, 2015 13:47:26 PM

if a pt does not notify its hmo that they moved out of area and is admitted as an emergency to out of area hospital can they be held responsible. Insurance is denying claim even after appeal on the basis that pt did not notify ins and hospital is out of area, they are aware that it was an emergency

SuperCoder Answered Thu 07th of May, 2015 05:10:49 AM

HMOs are required to provide coverage for medically necessary emergency care outside of its service area. If you receive emergency care outside of the HMO's service area you should contact your HMO within 48 hours. However, if your HMO determines your condition was not an emergency and not medically necessary, it could refuse to pay the emergency room charges.

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