Urgent and Emergency Care

Members who urgently need services should call the 24/7 Medical Advice Line at 1.866.682.9492 (toll-free) for all holidays, weekends and after-hours care, or their Primary Care Physician Urgently needed services are covered when: a) The Member’s condition meets the definition of urgently needed services (see Section 15: Glossary of Terms), and b) Members use the network of VHPs Urgent Care Locations or c) The Member obtains authorization from the VHP Utilization Management (UM) Department (or the advice nurse) before seeking treatment from a non-VHP provider when the Member is temporarily out of the service area and medical care cannot be delayed until the Member returns.

In an emergency, VHP Members should call 911 or go to the nearest emergency room. Emergency services are covered when furnished by VHP providers or non-VHP providers if the following requirement is met: “Emergency Services”, as set forth in Title 22, California Code of Regulations (“CCR”), section 51056, and California Health and Safety Code section 1317.1, means those services required for alleviation of 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 any of the following: a) placing the patient’s health (or in the case of 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. Emergency Services also includes screenings, examinations, and evaluations for the purpose of determining whether a psychiatric emergency condition exists, and for which treatment is necessary to relieve or eliminate the psychiatric emergency condition. The final determination as to whether such services were emergency services rests solely with VHP. When it is necessary to receive emergency services from a non-VHP provider, Members should present their VHP ID card and ask the provider or someone acting on the Member’s behalf to call VHP at 1-888-421-8444. VHP must be notified within 48 hours or as soon as reasonably possible.

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