Emergency care: Definition

AZ | AZBH | CA | CO | CT | DE | DC | FL | HI | HIBH | IL | IN | IA | KS | KY | ME | MD | MA
MI | MN | MO | MT | NE | NEBH | NV | NH | NJ | NM | NY | NC ND | OH | OK | OR | ORMH
PA | PABH | SC | TN | UT | UTMH | VA | WA | WV | WI



AZ

"SECTION C: DEFINITIONS...
EMERGENCY MEDICAL CONDITION      A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part. (42 USC 13960-2)

EMERGENCY MEDICAL SERVICE       Services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: a) placing the patient’s health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part."  Arizona Contract, pages 3-4.

"SECTION D:  PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES…
Emergency services: The Contractor shall have and/or provide the following as a minimum: ...For utilization review, the test for appropriateness of the request for emergency services shall be whether a prudent layperson, similarly situated, would have requested such services.  For purposes of this contract, a 'prudent layperson' is defined as a person without medical training who exercises those qualities of attention, knowledge, intelligence and judgment which society requires of its members for the protection of their own interest and the interests of others.  The phrase does not apply to a person’s ability to reason, but rather the prudence with which he acts under a given set of circumstances..."  Arizona Contract, pages 10, 12.

AZBH

"EMERGENCY MEDICAL CONDITION
Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:  a)  placing the patient's or others' health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part."  Arizona Behavioral Health Contract, page 5.

"43.  SUBCONTRACTS...
In addition, each contract with a RBHA and each RBHA subcontract with a provider must contain the following provisions: ...
p.  A provision that emergency services do not need prior authorization and that, in utilization review, the test for appropriateness of the request for emergency services shall be whether a prudent layperson, similarly situated, would have requested such services.  For purposes of this contract, a 'prudent layperson' is defined as a person without medical training who exercises those qualities of attention, knowledge, intelligence and judgement which society requires of its members for the protection of their own interest and the interests of others.  The phrase does not apply to a person's ability to reason, but rather the prudence with which he acts under a given set of circumstances."  Arizona Behavioral Health Contract, pages 34-35.

CA

"ARTICLE II - DEFINITIONS...
DD. Emergency Medical Condition means a medical condition which is manifested by acute symptoms of sufficient severity (including severe pain), such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
1. placing the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
2. serious impairment to bodily function, or
3. serious dysfunction of any bodily organ or part."  California Contract, pages 2, 7.

CO

"I. DEFINITIONS
The following terms as used in this Contract shall be construed and interpreted as follows unless the context otherwise expressly requires a different construction and interpretation: ...

AC.  'Emergency or Emergent' shall mean the sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.  Benefits cannot be denied for conditions which a prudent lay person would perceive as emergency medical conditions as specified by the Division of Insurance Regulation 4-2-17, Section 6.G."  Colorado Contract, page 4.

"EXHIBIT A
COVERED SERVICES…
A.11  Emergency Medical Care
Emergency medical condition means the sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy. Benefits cannot be denied for conditions which a prudent lay person would perceive as emergency medical conditions as specified by the Division of Insurance Regulation 4-2-17, Section 6.G."  Colorado Contract, Exhibit A, page 24.

CT

"Part II:  General Contract Terms for MCOs
1.  Definitions...
L.  Emergency:  A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any body organ or part…"  Connecticut Contract, pages 11-12.

DE

"5.10.2 Member Handbook Minimum Contents...
The Federal Definition of Medical Emergency:
a)  `Emergency Services' means, with respect to an individual enrolled with an MCO, covered inpatient and outpatient services that they:
(i)  are furnished by a provider that is qualified to furnish such services under this title, and
(ii)  are needed to evaluate or stabilize an emergency medical condition (as defined in subpart. (b)

b)  `Emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in;
(i)  placing the health of the individual (or with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy,
(ii)  serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part…"  Delaware RFP, pages II.20-II.22.

"7.2  Describe the methods used, including monitoring, to assure access to covered services, including emergency services (2102(A)(7)(B))...

The state requires the 'prudent layperson' language for emergency services as defined by the BBA of 1997…"  Delaware RFP, Appendix A (SCHIP), page A.33.

DC

"ARTICLE XXII - DEFINITIONS...
I.   The term 'emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in -
  1.  Placing the health of the individual (or, with respect to a pregnant woman the health of the woman or her unborn child) in serious jeopardy,
  2.  Serious health impairment of bodily functions, or
  3.  Serious dysfunction of any bodily organ or part."  District of Columbia Contract, pages 48-49.

FL

"24.  Emergency Medical Condition… (an emergency medical condition is: (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person, pursuant to Section 4704 of the 197 Balanced Budget Act, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) serious jeopardy to the health of a patient, including a pregnant woman or a fetus.  2) serious impairment to bodily functions.  3) serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman:  1) that there is inadequate time to effect safe transfer to another hospital prior to delivery.  2) that a transfer may pose a threat to the health and safety of the patient or fetus.  3)  that there is evidence of the onset and persistence of uterine contractions or rupture of the membrane."  Florida Contract, page 154.

HI

"41.020 Emergency Room...
 HCFA defines the circumstance under which payment is required as 1) the services were needed immediately because of an injury or sudden illness; and 2) the time required to reach the contractor's facilities, or the facilities of a provider with which the contractor has arrangements, would have meant risk of permanent damage to the recipient's health…" Hawaii RFP, page 55.

"Medical emergency - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part"  Hawaii RFP, Appendix A, page 4.

"Emergency and Urgent Services...
1.  Emergency services are services which are needed immediately.
2.  Emergency services which are medially necessary to prevent death or serious impairment of health provider by hospitals which are certified to participate in Medicare are included…"  Hawaii RFP, Appendix H, page 15.

HIBH

"41.020  Emergency Room...
HCFA defines the circumstances under which payment is required as 1) the services were needed immediately as a result of injury or sudden illness; and 2) the time required to reach the contractor's facilities, or the facilities of a provider with which the contractor has arrangements, would have meant risk of permanent damage to the member's health.  Psychiatric emergency services include inpatient and outpatient services."  Hawaii Behavioral Health RFP, page 44.

"Emergency Services - services or treatment, which omitted, would seriously and immediately endanger the life or safety of a consumer or others…"  Hawaii Behavioral Health RFP, page A4.

IL

"Emergency Care or Emergency Services means the provision of those health care services for a medical condition of recent onset and severity that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that emergent medical care is required. Determination of levels of service shall be based upon the symptoms and condition of the Beneficiary at the time the Beneficiary is initially examined by the Physician and not upon the final determination of the Beneficiary's actual medical condition."  Illinois HMO Contract, page 3.

IN

"Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Emergency Services - With respect to an individual enrolled with a managed care organization, covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish such services and are needed to evaluate or stabilize an emergency medical condition."  Indiana RFP, page 1-3.

IA

"1.3  Definitions...
-Emergent Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect it to result in:
1.  Placing the health of the person or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy,
2.  Serious impairment to bodily functions, or
3.  Serious dysfunction of any bodily organ or part.
The determination of whether an Emergent Medical Condition exists shall be decided by a medical professional and shall be based on the Enrollee's medical condition, including presenting symptoms and medical history (as related to severe pain) prior to treatment."  Iowa Contract, pages 6-7.

KS

"Emergency Services - covered services that are needed immediately or appear to be needed immediately because of an injury, sudden illness or sudden change in the severity of an illness and in which additional delay would mean an additional risk of serious damage to the member's health.

Emergent Primary Care Services - those services provided in a physician's office in response to an emergency (e.g., high temperature, persistent vomiting or diarrhea, or symptoms which are of a sudden or severe onset but which do not require emergency room services."  Kansas Contract, Appendix E, page 3.

"B.  1.  COVER EMERGENCY SERVICES UNDER 'PRUDENT LAYPERSON' DEFINITION  Contract Section IIC, page 6, and Exhibit E, Definitions are amended by adding the following language under Emergency room services based on medical necessity:
    A.  MCO agrees to cover (pay for) emergency services for Medicaid HMO members who seek emergency treatment for any medical condition…that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part...
    D… 2.  APPENDIX E DEFINITIONS
Appendix E shall be modified to replace the Emergency Services definition with the Prudent Layperson definition as follows: 'Emergency services means covered inpatient and outpatient services that are needed to evaluate or stabilize an emergency medical condition that is found to exist using a prudent layperson standard.'"  Kansas Contract, Amendment One.

KY

"Emergency Medical Condition : Emergency services are to cover inpatient and outpatient services furnished by a qualified provider and are needed to evaluate or stabilize an emergency medical condition. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
  (a)  Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child);
  (b)  Serious impairment to bodily functions;
  (c)  Serious dysfunction of any bodily organ or part."  Kentucky Contract, pages 11-12.

"7.9.1 Medicaid Covered Services...
  Emergency services are defined by the Balance Budget Act (BBA) of 1997 § 4704 of the BBA and codified in §1932(b)(2) of the Social Security Act and as such will override the definition currently in 907 KAR 1:705 Section 1 Definitions and Section 7 (2).  Emergency services are to cover inpatient and outpatient services furnished by a qualified provider and are needed to evaluate or stabilize an emergency medical condition.  An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions, or (3) serious dysfunction of a bodily organ or part."  Kentucky RFA, pages 68-69.

"Emergency services are defined by the Balance Budget Act (BBA) of 1997 § 4704 of the BBA and codified in §1932(b)(2) of the Social Security Act and as such will override the definition currently in 907 KAR 1: 705 Section 1 Definitions and Section 7 (2).  Emergency services are to cover inpatient and outpatient services furnished by a qualified provider and are needed to evaluate or stabilize an emergency medical condition.  An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) such reasonably expect the absence of immediate medical knowledge of health and medicine, could the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions, or (3) serious dysfunction of a bodily organ or part."  Kentucky RFA, Attachment VIII, page 63.

ME

"II.  DEFINITIONS.
A.  The following terms used in this Contract shall be interpreted as defined herein, except to the extent that the context may clearly require otherwise: ...
22.  Emergency Services means (i) a medical condition manifesting itself by acute symptoms of  sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; or (ii) with respect to a pregnant woman who is having contractions, a situation where there is not adequate time to effect a safe transfer to another hospital before delivery, or transfer may pose a threat to the health or safety of the woman or the fetus."  Maine Contract, pages 2, 4.

MD

"Dear State Medicaid Director: ...
The purpose of this letter is to advise you of the changes made by the BBA regarding coverage of emergency services by managed care organizations (MCOs)...

The BBA defines emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part.  While this standard encompasses clinical emergencies, it also clearly requires MCOs to base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and to cover examinations where the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson."  Maryland Contract, HCFA State Medicaid Letter, 2/20/98.

"Chapter 62  Maryland Medicaid Managed Care Program:  Definitions
.01  Definitions…
(44)  'Emergency medical condition' means a medical condition characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:
(a)  Placing the patient's health in serious jeopardy;
(b)  Serious impairment to bodily functions; or
(c)  Serious dysfunction of any bodily organ or part...

(45)  'Emergency services' means those health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:
(a)  Placing the patient's health in serious jeopardy;
(b)  Serious impairment to bodily functions; or
(c)  Serious dysfunction of any bodily organ or part."  Maryland COMAR 10.09.62.01.

MA

"SECTION 1. DEFINITION OF TERMS...
Emergency Medical Condition - a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  (1)  placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part…"  Massachusetts Contract, pages 6-10.

MI

"DEFINITIONS/EXPLANATION OF TERMS...
Emergency Medical Care
Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (i) 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; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part…"  Michigan Contract, pages vi-vii.

MN

"Section 2.29. Medical Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who -possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; , continuation of severe pain; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or death. Labor and delivery is a Medical Emergency if it meets this definition."  Minnesota Contract, page 13.

MO

"b.  Covered Services...
23)  Emergency medical services.  Emergency medical services are defined as those health care items and services furnished or required to evaluate or stabilize a sudden and unforeseen situation or occurrence or a sudden onset of a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent lay person, possessing average knowledge of health and medicine, to result in:
*  placing the patient's health (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or
* serious impairment if bodily functions; or
* serious dysfunction of any bodily organ or part; or
* serious harm to a member or others due to an alcohol or drug abuse emergency; or
*  injury to self or bodily harm to others; or
* with respect to a pregnant woman who is having contractions: (1) that there is inadequate time to effect a safe transfer of another hospital before delivery or in (2) that transfer may pose a threat to the health or safety of the woman or the unborn."  Missouri RFP, page 10.

"Services shall include...
aa.  Emergency medical services.  Emergency medical services are defined as those health care items and services furnished or required to evaluate or stabilize a sudden and unforeseen situation or occurrence or a sudden onset of a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent lay person, possessing average knowledge of health and medicine, to result in:
1)  placing the patient's health (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or
2)  serious impairment of bodily functions; or
3)  serious dysfunction of any bodily organ or art; or
4)  serious harm to a member or others due to an alcohol or drug abuse emergency;
5)  injury to self or bodily harm to others;
6)  with respect to a pregnant woman who is having contractions:  (2) that there is inadequate time to effect a safe transfer to another hospital before delivery or, (2) that transfer may pose a threat to the health or safety of the woman or the unborn."  Missouri RFP, page 19.

MT

"EMERGENCY MEDICAL CONDITION- a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in:
1.  Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
2.  Serious impairment to bodily functions; or
3  Serious dysfunction of any bodily organ or part."  Montana Contract, page 27.

NE

"4.1.16 The term 'Emergency Medical Condition' means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, 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:
(a) Placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
(b) Serious impairment to such person’s bodily functions;
(c) Serious impairment of any bodily organ or part of such person; or
(d) Serious disfigurement of such person."  Nebraska Contract, page 8.

"13.48.4 Emergency Medical Condition Defined: An emergency medical condition is a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, 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:
(a) Placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such persons or others in serious jeopardy;
(b) Serious impairment to such person’s bodily functions; or
(c) Serious impairment of any bodily organ or part of such person."  Nebraska Contract, page 97.

NEBH

"4.1  Applicable Definitions: The following definitions apply under this contract: ...
4.1.12  The term ‘Emergency Medical Condition’ means a medical or behavioral health condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, 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:
(a)  Placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
(b)  Serious impairment to such person’s bodily functions;
(c)  Serious impairment of any bodily organ or part of such person; or
(d)  Serious disfigurement of such person."  Nebraska Behavioral Health Contract, pages 6-7.

"11.54.4  Emergency Medical Condition Defined:  An emergency medical condition is a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, 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:
a) Placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such persons or others in serious jeopardy;
b) Serious impairment to such person’s bodily functions, or
c) Serious impairment of any bodily organ or part of such person."  Nebraska Behavioral Health Contract, page 67.

NV

"DEFINITIONS
Emergency Medical Condition:  A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) as perceived by a prudent layperson, possessing an average knowledge of health and medicine, who could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part…

Emergency Services:  Emergency services means, with respect to an individual enrolled with an organization covered inpatient and outpatient services that are furnished by a provider qualified to furnish such services, and are needed to evaluate or stabilize an emergency medical condition."  Nevada Contract, page 16.

NH

"Article I
Definitions...
1.22  The term 'Emergency Services' means medical or other health services which are immediately required due to injury or sudden illness which, if not treated could reasonably be expected to result in permanent damage to an Enrollee's health…"  New Hampshire General Service Agreement, page 5.

NJ

"1.35 'Emergency Medical Condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent layperson who possesses and average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction or any bodily organ or part."  New Jersey Contract, page 12.

NM

"4.  Article 2, Section 2.A.1.e.i., is amended as follows:
2.A.l.e.i.(D)...
  (3)  that an emergency condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson. who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part..."  New Mexico Contract, Amendment #1, pages 1-2.

"9.  Article 2. Section 2.D.5., is amended as follows:
2.D.5.  Emergency services
  2.D.5.a.  Coverage of emergency services by the MCO will be determined under the prudent lay person standard. The MCO must cover cases where presenting symptoms (including severe pain) are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part."  New Mexico Contract, Amendment #1, page 3.

NY

"1.  DEFINITONS…
'Emergency Medical Condition' means 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: (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; or (ii) serious impairment to such person's bodily functions; or (iii) serious dysfunction of any bodily organ or part of such person; or (iv) serious disfigurement of such person…"  New York Contract, page 1-2.

NC

"APPENDIX I
DEFINITION OF TERMS…
1.19  Emergency Medical Condition --
(A)  A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
  (1)  placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy
  (2)  serious impairment to bodily functions, or
  (3)  serious dysfunction of any bodily organ or part; or
(B)  With respect to a pregnant woman who is having contractions:
  (1)  that there is inadequate time to effect a safe transfer to another hospital before delivery, or
  (2)  that transfer may pose a threat to the health or safety of the woman or the unborn child.

1.20  Emergency Medical Services- with respect to an individual enrolled with an organization, covered inpatient and outpatient services that:
(A)  are furnished by a provider that is qualified to furnish such services; and,
(B)   are needed to evaluate or stabilize an emergency medical condition as defined above."  North Carolina Contract, Appendix I.

ND

"ATTACHMENT C:  CONTRACT TERMS FOR HMOs...
1.1  Definitions
The following terms and definitions apply to this contract and all of its attachments...
Emergency care - A medical condition which most non-medical people think is life-threatening or could cause death or severe, permanent damage or injury to a person or unborn baby if not treated immediately."  North Dakota Contract, Attachment C, pages 1, 3.

OH

"4.  Emergency Department (ED) Diversion...
ODHS requires compliance with the prudent layperson standard.  An emergency medical condition is therefore determined based on the enrollee's perception of the nature and severity of their systems at the time of presentation to the emergency care setting…"  Ohio RFP, pages 19-20.

"5101:3-26-01  Managed care plan:  Definitions.
As used in Chapter 5101:3-26 of the Administrative Code: …
(U)  'EMERGENCY MEDICAL CONDITION' MEANS A MEDICAL CONDITION MANIFESTING ITSELF BY ACUTE SYMPTOMS OF SUFFICIENT SEVERITY (INCLUDING SEVERE PAIN) SUCH THAT A PRUDENT LAYPERSON, WHO POSSESSES AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE, COULD REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO RESULT IN ANY OF THE FOLLOWING:  PLACING THE HEALTH OF THE INDIVIDUAL (OR, WITH RESPECT TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD) IN SERIOUS JEOPARDY; SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; OR SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART."  Ohio RFP, Appendix E, OAC 5101:3-26-01, page 2.

OK

"1.4  Definitions
Each of the following terms shall have the indicated meanings unless the context clearly requires otherwise: ...

29.  EMERGENCY MEDICAL CONDITION means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in:
  1.  Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy; or
  2.  Serious impairment to any bodily functions or
  3.  Serious dysfunction of any bodily organ or part…"  Oklahoma RFP, pages 5, 7-8.

OR

"E.  Capitated Services...

F.  Emergency Services
(1)  Contractor's obligation to pay for Emergency Services under Section 3A(1) of this Agreement that are received from providers other than Contractor or its subcontractors is limited to Covered Services provided for diagnosis and treatment of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the individual (or with respect to a pregnant woman, the health of both the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. (See OAR 410-141-0000, Definition of Terms, for additional information as it applies to dental services provided in a hospital emergency room.)…"  Oregon Contract, pages 7-8.

ORMH

"V. Statement of Work...
2.  Provision of Covered Services…
d.  Contractor's obligation to pay for Emergency Services that are received from non Participating providers is limited to Covered Services that are needed immediately and the time required to reach a Contractor or a participating Provider (or alternatives authorized by Contractor) would have meant substantial risk to the OMAP Member's health or safety or the health or the safety of another...

e. Contractor shall pay for emergency screening if condition was determined to be non- emergent, but presenting condition met prudent layperson definition…"  Oregon Mental Health Contract, page 7.

"d.  24 Hour Urgent and Emergency Response System
(1) Contractor shall provide Covered mental health Emergency Services that are needed immediately, or appear to be needed immediately by a prudent layperson, because of a sudden mental health condition, or exacerbation of a mental health condition…"  Oregon Mental Health Contract, page 14.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Emergency Situation: A mental Health condition, manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of the OMAP Member, (2) serious impairment of bodily function, or (3) serious dysfunction of any bodily part or part."  Oregon Mental Health Contract, Appendix K, pages K1, K7.

PA

"Emergency Services-Services provided after the sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the prudent layperson would believe that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or ( c )  serious dysfunction of any bodily organ or part.  This includes active labor..."  Pennsylvania RFP, page ix.

PABH

"Request for Proposals (RFP) Definitions
For the purpose of this Health Choices behavioral health services RFP, the definitions set forth shall apply...

Emergency Behavioral Health Services -Services provided after the sudden onset or exacerbation of behavioral health condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate behavioral health attention could reasonably be expected to result in:
  - serious bodily harm or injury;  or
  - serious physical debilitation

Emergency Room Services - Any services rendered in a general hospital emergency room regardless of presenting problem or primary diagnosis."  Pennsylvania Behavioral Health RFP, pages 3, 5.

SC

"Emergency Services - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."  South Carolina Contract, page A3.

TN

"Attachment I - Definitions...
16.  Emergency Medical Services - a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:
  a.  Permanently placing an enrollee's health in jeopardy,
  b.  Causing other serious medical consequences,
  c.  Causing impairments to body functions, or
  d.  Causing serious or permanent dysfunction of any body organ or part…"  Tennessee Contract, pages 90-93.

UT

"ATTACHMENT B - Special Provisions
Article I - Definitions...
F.  'Emergency Services' means those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:
  1.  Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;
  2.  Serious impairment to bodily functions; or
  3.  Serious dysfunction of any bodily organ or part."  Utah Contract, Attachment B, page 1.

UTMH

"Article I
DEFINITIONS…
'Emergency' means a psychiatric condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in -
  a.  Placing the health or safety of the Enrollee (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
  b.  Placing the health or safety of other individuals in serious jeopardy; or
  c.  Serious impairment to bodily functions or serious dysfunction of any bodily organ or part."  Utah Mental Health Contract, page 1.

"Article III
SCOPE OF SERVICES...
A.  Covered Services...
  5.  Emergency Services...
  c.  The CONTRACTOR must pay for Emergency Services where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
  d.  The CONTRACTOR may not retroactively deny a claim of Emergency Services because the condition, which appeared to be an Emergency under the prudent layperson standard, turned out to be non-emergency in nature.  In these cases, the CONTRACTOR  must review the presenting symptoms of the Enrollee and must pay for Emergency Services where the presenting symptoms were of sufficient severity to have warranted emergency attention under the prudent layperson standard."  Utah Mental Health Contract, page 5.

VA

"ARTICLE I - DEFINITIONS...
Emergency Medical Condition - Coverage of emergency services by the Contractor will be determined by the 'prudent layperson' standard.

Emergency Services - Covered inpatient and outpatient services furnished by a qualified Medicaid provider that are necessary to evaluate or stabilize an emergency medical condition.  Contractor must cover cases where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in (i) placing their health or the health of an unborn child in immediate jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part."  Virginia Contract, pages 7-8.

WA

"1.4  Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  (a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part (42 USC 1396u-2(b)(2)(C))."  Washington Contract, Page 1.

WV

"3.7 Emergency Services...
Emergency care services include those services needed immediately and are provided for conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy; serious impairment of bodily functions; or serious dysfunction of any bodily organ or part. These include accidental injury and poison-related problems and complaints which may be indicative of serious, life-threatening medical problems, e.g. chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness...

The Managed Care Plan is required to inform enrollees of the following regarding their rights of access to, and coverage of, emergency services, both inside and outside of the plan's network: ...

*  Definition of Emergency Medical Condition: Coverage of emergency services by the Managed Care Plan will be determined under the prudent layperson standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The Managed Care Plan must cover cases where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in:
  - placing their health or the health of an unborn child in immediate jeopardy,
  - serious impairment of bodily functions, or
  - serious dysfunction of any bodily organ or part."  West Virginia Contract, pages 10-11.

"2.2 Emergency Care...
Emergency care services include those services provided for conditions which pose a potential threat to the patient of loss of life or limb or significant impairment. These include accidental injury and poison-related problems and vague complaints which may be indicative of serious, life-threatening medical problems, e.g. chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests examination, a nurse triage screening is always allowed."  West Virginia RFA, page 13.

WI

"The term 'emergency medical condition' means - A. a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
1.  placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
2.  serious impairment of bodily functions, or
3.  serious dysfunction of any bodily organ or part; or
B.  with respect to a pregnant woman who is in active labor -
1.  that there is inadequate time to effect a safe transfer to another hospital before delivery; or
2.  that transfer may pose a threat to the health or safety of the woman or the unborn child.
C.  a psychiatric emergency involving a significant risk of serious harm to oneself or others.
D. a substance abuse emergency exists if there is significant risk of serious harm to an enrollee or others, or there is likelihood of return to substance abuse without immediate treatment.
E. Emergency dental care is defined as an immediate service needed to relieve the patient from pain, an acute infection, swelling, trismus, fever, or trauma. In all emergency situations, the HMO must document in the recipient's dental records the nature of the emergency."  Wisconsin Contract, pages 2-3.