IN CASE OF AN EMERGENCY

Emergency care is provided at nearly all Plan Hospitals 24 hours a day, 7 days a week. If you are not sure whether your situation is an emergency, call the Emergency Department at your local Plan Hospital and we will advise you on the appropriate action to take. Refer to The Guidebook to Kaiser Permanente Services or your local telephone directory for telephone numbers. For life-threatening conditions, call 911 immediately.

For urgent care, call one of Kaiser Permanente’s telephone advice nurses who are registered nurses (RNs) specially trained to help assess medical problems and provide medical advice. They can help solve a problem over the phone and instruct you on self-care at home if appropriate. If the problem is more severe and you need an appointment, they will help you get one.

Refer to The Guidebook to Kaiser Permanente Services for non-emergency appointments. If you don't have a Guidebook, call one of Kaiser Permanente’s Member Service representatives toll-free at 1-800-464-4000 to request one.

Services Received At An Out-Of-Plan Facility

To be eligible for this benefit, you must notify Kaiser Permanente within 24 hours after care begins (or as soon as reasonably possible). This benefit is provided only for emergency treatment required before your condition permits transfer to a Plan facility. Medically necessary special transportation is covered with prior approval from a Kaiser Permanente physician.

Kaiser Permanente may arrange for your transfer to a Plan facility as soon as it is medically appropriate to do so. This benefit applies only to care that is a covered service under the Kaiser Permanente service agreement.

Your enrollment packet included The Guidebook to Kaiser Permanente Services, which lists Kaiser Permanente phone numbers to call in case of an emergency. These phone numbers are also on the back on your Kaiser Permanente I.D. card.

Services At Out-Of-Plan Facilities Outside Kaiser Permanente Service Area

If you are injured or become unexpectedly ill while you are outside our Service Area, we will cover Out-of-Plan Emergency Services that could not reasonably be delayed until you could get to a Plan Facility.

Services At Out-Of-Plan Facilities Within Kaiser Permanente Service Area

If you are within our Service Area, we will cover Out-of-Plan Emergency Services only if going to a Plan Facility for treatment would have caused a delay resulting in permanent damage to your health.

Limitations on Benefits for Services Received From Out-Of-Plan Physicians or Facilities

1. Kaiser Permanente will pay only what they determine to be reasonable and customary charges for care received from out-of-plan providers. Any amounts in excess of what Kaiser Permanente considers reasonable and customary must be paid by you.


2. Any other health care coverage program (Medicare, insurance, government programs, etc., but not including Medicaid/Medi-Cal or Medicare for members who have elected, under federal law, to have their group contract benefits primary and Medicare benefits secondary) is payable first before your Kaiser Permanente benefit for emergency services at an out-of-plan facility is payable. However, if payment under the other program is not made within a reasonable amount of time, Kaiser Permanente will pay the physicians and facilities who provided the care if you:
   1. Assign all other benefits to Kaiser Permanente and agree to fully cooperate with Kaiser Permanente in obtaining these benefits.
   
   
   2. Allow Kaiser Permanente to obtain confirmation from the source of other benefits that such benefits have not already been paid, and
   
   
   3. Furnish Kaiser Permanente with any information necessary to implement these provisions.


3. Payments under this benefit are subject to reduction if you may have been injured through the fault of someone else.