5 Questions
Health plans base reimbursement on the final diagnosis rather than a patient's presenting symptoms.
False
If a patient's severe chest pain turns out to be heartburn rather than a heart attack, the health plan must cover the emergency department care.
True
Urgent and Emergent claims are considered at the Out of Network (OON) benefit level.
False
Severe and/or persistent vomiting is commonly identified as an Urgent / Emergent condition.
True
If the provider is in-network and the claim is denied, it is the provider's responsibility.
True
Test your knowledge of CMS's 'Prudent Layperson' definition for categorizing emergency conditions and its impact on health plan reimbursement.
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