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El Paso Emergency Room Guidelines

Prudent Layperson Standard

The prudent layperson standard forces insurance companies to consider your symptoms in determining if a claim is reimbursed rather than the final diagnosis.  The classic example is if you present to the ER with chest pain, and the final diagnosis winds up being acid reflux.  There is no way a prudent layperson would be able to distinguish the two without further testing.

This is important because 90-95% of urgent and non-urgent symptoms overlap and you cannot distinguish the two without a proper exam and testing.

The Prudent Layperson Standard defines an “emergency medical condition” as one that manifests 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 placing the health of the individual in serious jeopardy, serious bodily functions, or serious dysfunction of any bodily organ or part.

In-Network vs Out-of Network Emergency Room

You are empowered by Texas state law to use the prudent layperson standard when deciding if you are having a medical emergency.

Guidelines set by the state of Texas require insurance carriers to pay in-network benefits to members receiving emergency medical treatment. It is Texas law that your insurance provider pay for your emergency room treatment, even if the provider typically classifies the facility as “out-of-network.”

 

Your insurance provider is required to reimburse you for emergency treatment. If your insurance company is refusing to reimburse you for your emergency room visit, you may file an official complaint with the Texas Department of Insurance. 

If you think you’ve been wrongly billed -

Please contact the federal No Surprises Help Desk at (800) 985-3059 or

Texas Department of Insurance (TDI) at (800) 252-3439

Visit https://www.cms.gov/nosuprises/consumers for more information about your rights under federal law.

Visit https://www.tdi.texas.gov/medical-billing/surprises-balance-billing.html for more information about your rights under Texas Law.

Senate Bill 425

  • El Paso Emergency Room is an emergency room.


  • El Paso Emergency Room charges rates comparable to a Hospital emergency department, including a facility fee.


  • The physician may bill separately from the facility.


  • El Paso Emergency Room and facility-based physicians are not a participating provider in an individual’s health plan network.

 

Senate Bill 425 

https://capitol.texas.gov/tlodocs/84R/billtext/html/SB00425F.HTM

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