We recognize, however, that there are ways to further improve and enhance the program," Anthem said.Īnthem has implemented the avoidable ER policy in Georgia, Missouri, Ohio, Indiana, New Hampshire and Kentucky. "Anthem's avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. Anthem said it is striving to make healthcare more affordable and to encourage consumers to receive care in the most appropriate setting. However, the insurer said it stands by its belief that emergency rooms are an expensive place to receive routine care. "We are applying our new and enhanced procedures to previously denied claims, and will overturn decisions where the new procedures would have resulted in an approval,"Īdditionally, Anthem is requesting medical records from the hospital as part of the initial review process. "We will continue to review this list and may expand it," Anthem said in a statement. Monday, and any visit where the patient receives surgery, IV fluids, IV medications or an MRI or CT scan. These exceptions include provider and ambulance referrals, services delivered to patients under the age of 15, visits associated with an outpatient or inpatient admission, emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away, visits 8 a.m. Providers have said it puts patients in harm's way when they have to decide whether their conditions constitute an emergency.Īs of January 1, Anthem said it would always pay for ER visits based on certain conditions. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.Responding to numerous objections of its emergency room policy, Anthem has tweaked its decision not to cover ER visits if the medical condition is not an emergency. Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. Note: Some costs do not count toward this protection.
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