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Urgent and Emergency Care

AmeriHealth Caritas Iowa members who require emergency care should be advised to call 911 if they are unable to transport themselves to the emergency room.

We ensure emergency services and care are available 24 hours a day, seven days a week. We are responsible for coverage and payment of emergency and post-stabilization care services, regardless of whether the provider who furnishes the services has a contract with AmeriHealth Caritas Iowa.

Definitions and requirements regarding urgent/emergent care are as follows:

Emergency medical conditions

An emergency medical condition is a physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) 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:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
  • Serious impairment to bodily functions.
  • Serious dysfunction of any bodily organ or part.

Emergency services

Emergency services are covered inpatient and outpatient services that are:

  • Furnished by a provider that is qualified to furnish these services; and
  • Are needed to evaluate or stabilize an emergency medical condition.

Emergency services are those medical services rendered under unforeseen conditions which require hospitalization for the treatment of accidental injury and relief of acute pain, which, if not immediately diagnosed and treated, would result in risk of permanent danger to the patient's health. (441 IAC 88.21)

Urgent, nonemergency need

Urgent, nonemergency need is the existence of conditions due to an illness or injury which are not life threatening but require expeditious treatment because of the prospect of the condition worsening without immediate clinical intervention. (441 IAC 88.21)