Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever.
Usual Customary and Reasonable Charge (UCR)
The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).
A review to determine whether covered services that have been provided or are proposed to be provided to you, whether undertaken prior to, concurrent with, or subsequent to the delivery of such services are medically necessary. See also: Coordinated Care.
Utilization Management Agent
EmblemHealth or any Utilization Management agent performing Utilization Management under a contract with EmblemHealth on behalf of EmblemHealth.
Utilization Management Appeal
The process by which you or your representative may request review of a denied service(s) based upon an adverse determination made by EmblemHealth.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans.