Can an HMO deny benefits for the treatment of injuries employees sustained as a result of the attack on the WTC because they didn call their primary care physician before getting care?
A. An HMO cannot require its members to get “prior authorization” (that is, permission from them) to use the emergency room or any emergency services. However, all claims for coverage of emergency services will be reviewed to determine if the services were medically necessary to stabilize or treat an emergency condition. HMOs typically require their members to call as soon as reasonably possible after receiving emergency services.
Related Questions
- Can an HMO deny benefits for the treatment of injuries employees sustained as a result of the attack on the WTC because they didn call their primary care physician before getting care?
- Can a plan deny benefits otherwise provided for the treatment of an injury based on the source of that injury?
- What benefits are provided by the Act if the injuries sustained by the worker are permanent in nature?
