When should I go to the ER?

Using good judgement in deciding when to use emergency medical services is very important. Learn the signs of serious illnesses and trust your instincts. If you are alarmed by unusually severe symptoms, it is best to seek immediate care.

Call your Primary Care Physician (PCP) and describe your symptoms. Your PCP can tell you whether emergency treatment is necessary. For urgent problems that don’t require emergency care, most doctors can accommodate same day appointments.

Gulf South’s Primary Care Physicians must have coverage available 24 hours a day for emergencies so it’s important to attempt to contact your doctor or the on-call physician even if its after office hours or on a weekend. Many doctors now keep their offices open after hours or on weekends for urgent problems.

In certain service areas and for certain beneficiary groups, Gulf South has contracted with free-standing urgent care centers. For acute minor illnesses, urgent care centers present a much faster and more economical solution than seeking care in a hospital Emergency Department.

If you are out of the Service Area, the usual, customary, and reasonable charges for emergency services will be covered. If the emergency results in an inpatient admission, you or your representative are responsible for notifying your Primary Care Physician within 48 hours of the admission for Network benefits to be considered, and to ensure certification of the admission. In any event, you must notify your Primary Care Physician or Gulf South within 48 hours. If you do not do so, Non-Network benefits and the certification penalty will apply.
In the case of any emergency admission, in order to ensure Network benefits, you may be transferred to a Network hospital once you are medically able. If you do not wish to be transferred at that time, Non-Network benefits will be payable from then on.

What is an Emergency Medical Condition?

The term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in--

I. placing the health of the participant or beneficiary

II.with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy.

(B) serious impairment to bodily functions.

General Guidelines for Seeking Emergency Care:

Good Reasons to Seek Care in an Emergency Department:

  • Loss of consciousness
  • Signs of heart attack that last two minutes or more. These include; pressure, fullness, squeezing or pain in the center of the chest; tightness, burning or aching under the breastbone; chest pain with lightheadedness or pounding of the heart. Irregular heartbeats.
  • Signs of a stroke, including: sudden weakness or numbness of the face or one side of the body; sudden loss of vision, particularly in one eye; loss of speech, or trouble talking or understanding speech; sudden, severe headaches with no known cause; unexplained dizziness, unsteadiness or sudden falls, especially when accompanied by any other stroke symptoms.
  • Severe shortness of breath.
  • Bleeding that does not stop after 10 minutes of direct pressure.
  • Sudden, severe pain.
  • Poisoning or overdose (Note: if possible, call your local poison control center first and ask for immediate home treatment advice. Certain poisons should be vomited up at once while others should be diluted with water as soon as possible. Such preliminary treatment can be lifesaving.)
  • A severe or worsening reaction to an insect bit or sting, or to a medication, especially if breathing is difficult.
  • A major injury.
  • Unexplained stupor, drowsiness or disorientation.
  • Coughing up, vomiting or passing blood.
  • Severe or persistent vomiting.
  • Suicidal or homicidal feelings.

Illnesses or injuries for which care in an Emergency Department is not normally required:

  • Earache
  • Minor cuts when bleeding is easily controlled
  • Minor dog or animal bites where bleeding is controlled (see your physician – a rabies or tetanus shot may be needed.)
  • Sprains
  • Sunburn or minor burns from cooking.
  • An insect sting or bite or a delayed reaction from one. (If there is breathing difficulty go to the ER).
  • A skin rash.
  • Fever (if there is a convulsion, go to the ER).
  • Sexually transmitted diseases.
  • Colds and cough, sore throat, flu.

Does Gulf South Require an Authorization from My PCP in order to cover Emergency Department Care?

No authorization is required, however the reason for the Emergency Department visit must meet the definition of an Emergency Medical Condition above.