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Finding the Right Care When It’s Not an Emergency

August 17, 2017
Always call 911 or go immediately to the ER if you think it's a life-threatening situation. However, primary care doctors are in the best position to have a comprehensive view of their patient's health status and should be the first medical professional patients see with any non-emergency medical concerns. 
What if you can’t get an appointment with your primary care doctor?
Most non-emergency medical conditions can be treated at retail clinics, urgent care clinics or 24/7 telehealth services such as Virtual Care. Those alternatives typically are much less expensive for you than going to the emergency room.
What’s a non-emergency medical condition?
Concerns like:
  • Seasonal allergies
  • Athlete’s foot
  • Suture removals
  • Common cold symptoms  
If you chose to receive care for non-emergency ailments at the ER when a more appropriate setting is available, your claim will be reviewed using the prudent layperson standard* and potentially denied. The review by a medical director will take into consideration the symptoms that brought you to the emergency room even if the diagnosis turned out to be a non-emergency ailment.  
It's important to note that our 24/7 nurse line and online tools are always available to help members find the right care option for their neighborhood. We'll cover non-emergent ER visits if:
  • You were directed to the emergency room by another medical provider.
  • If services were provided to a child under the age 14.
  • If there isn’t an urgent care or retail clinic within 15 miles.
  • If the visit occurs on a Sunday or major holiday. 
If a member's claim for emergency services is denied because it does not meet the prudent layperson standard, the claim will be denied as member liability. Information on what to do next in this situation will be included with the denial letter.
*A prudent layperson has an average knowledge of health and medicine.