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2.1  The Advisory Commission on Consumer Protection and Quality in the Health Care Industry was appointed by President Clinton on March 26, 1997, to “advise the President on changes occurring in the health care system and recommend measures as may be necessary to promote and assure health care quality and value, and protect consumers and workers in the health care system.” As part of its work, the President asked the Commission to draft a “consumer bill of rights.”

2.2  In its report, the Commission stated that, “Consumers have the right to access emergency health care services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity--including severe pain--such that a ‘prudent layperson’ could reasonably expect the absence of medical attention to result in placing the consumer’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.” Emphasis is placed on the patient’s presenting symptoms rather than the final diagnosis.

2.3  In conjunction with the “prudent layperson” standard, TRICARE must also enforce the current provision that “appropriate medical care” required to provide “medically or psychologically necessary” services is to be furnished economically. That is, services are to be furnished in the least expensive level of care or medical environment adequate to provide the required medical care regardless of whether or not that level of care is covered by TRICARE. For care sought in an ED, which was clearly a case of routine illness where the beneficiary’s medical condition never was, or never appeared to be, an emergency, the ED is the inappropriate “medical environment” to seek the care. A physician’s office, for example, would be a more adequate medical environment for non-emergency care. Non-emergent visits to the ED can be costly, contribute to overcrowded waiting rooms, divert resources away from other hospital-based care, and compromise the coordination and continuity of care.

2.4  This policy encompasses the Commission’s recommendations and the TRICARE provision that benefits be extended for care that is “medically and psychologically necessary” and “appropriate medical care”.

4.1  For medical, maternity or psychiatric emergencies that would lead a “prudent layperson,” (someone with average knowledge of health and medicine), to believe that a serious medical condition existed or the absence of medical attention would result in a threat to his/her life, limb, or sight and requires immediate medical treatment or which manifest painful symptomatology requiring immediate palliative effort to relieve suffering. This includes situations where a beneficiary presents with severe pain.

4.2  For service and supplies, not otherwise excluded, that are ordered or administered in the ED to manage the care (e.g., tetanus toxoid injections, etc.).

5.1  Medical emergency is the sudden and unexpected onset of a medical condition or the acute exacerbation of a chronic condition listed that is threatening to life, limb, or sight, and requires immediate medical treatment or manifests painful symptomatology requiring immediate palliative efforts to alleviate suffering.

5.2  Maternity emergency is a sudden unexpected medical complication which puts the mother, or fetus, at risk.

5.3  A psychiatric inpatient admission is an emergency when, based on a psychiatric evaluation performed by a physician (or other qualified mental health care professional with hospital admission authority), the patient is at immediate risk of serious harm to self or others as a result of mental disorder and requires immediate continuous skilled observation at the acute level of care.

5.4  Since claims are submitted with only the discharge diagnosis (not presenting symptoms), any ED claim about to be denied shall be suspended and developed prior to actual denial. Development shall determine whether the presenting symptoms meet the prudent layperson standard defined in policy above.

5.5  Pre-authorization is not required for ED services meeting the above POLICY.

5.6  An adverse determination of ED care claims is an appealable issue.

5.7  Admissions resulting from a psychiatric emergency should be reported to the TRICARE contractor within 24 hours of admission or the next business day after admission but must be reported within 72 hours of the admission. In the case of an emergency admission, authorization resulting from approval of a request made within 72 hours of the admission, the effective date of the authorization shall be the date of the admission. If it is determined that the case was not an emergency admission (but the admission can be authorized as medically or psychologically necessary), the effective date of the authorization shall be the date of the receipt of the request or the date of admission, whichever occurs first (refer to the TRICARE Operations Manual (TOM)).

5.8  ED services as defined in “POLICY” above are cost-shared as follows: