§ 53855. Care Under Emergency Circumstances.

(a) Each plan in a designated region shall cover emergency medical services without prior authorization pursuant to title 10, CCR, section 1300.67(g) and title 22, CCR, section 53216. Each plan shall reimburse, without prior authorization, hospital emergency departments or emergency physicians for medical screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, for all services medically necessary to stabilize the plan member. If the medical screening examination indicates that the patient's condition does not constitute an emergency as defined in section 51056, hospital emergency departments or emergency physicians shall obtain prior authorization from the plan to render treatment. The plan may deny reimbursement for any services rendered to the member beyond the medical screening examination if the hospital emergency department or emergency physician fails to obtain prior authorization. Upon receipt of a request for such authorization from an emergency services provider, a plan shall render a decision upon the request within 30 minutes, or the request shall be deemed to be approved.

(b) Each plan shall maintain a 24-hour multilingual telephone contact number for handling emergencies. Each plan shall ensure that a physician is available 24 hours a day to: coordinate the transfer to a plan provider of a member whose condition is stabilized; or authorize medically necessary post-stabilization services. Each plan shall have a system to ensure continuity of care and follow-up care for all plan members for whom the plan has denied authorization for emergency services.

(c) A plan may subject all hospital emergency department and emergency physician claims to post-service, prepayment review for post-stabilization services; however claims for medical screening examinations shall not be denied without review. Each plan shall pay emergency services claims at the appropriate level based on the documentation submitted. All properly documented claims for medical screening examinations and emergency services rendered by noncontracted providers shall be paid by the plan within 45 days of receipt of a valid invoice. Each plan shall pay for all claims involving medically necessary services to diagnose and treat nonemergency conditions that the plan has prior authorized.

(d) Each plan shall arrange and make payment for emergency department, emergency physician and emergency transportation services, at the lesser of:

(1) The usual charges made to the general public by the emergency services provider,

(2) The maximum Medi-Cal fee-for-service rate, as specified in sections 51503 and 51509, or

(3) The rate negotiated between the plan and the provider of services for emergency services as defined in section 51056.

(e) For emergency inpatient hospital services, payment shall be made in accordance with the provisions in the contract between the plan and the department.

(f) If disputes arise over claims submitted by providers seeking reimbursement for the provision of emergency services to plan members, the parties shall adhere to the procedures and requirements prescribed in section 53875 for the resolution of such disputes.

(g) In the event the provision of emergency services to plan members is delegated to an entity, such entity, and any further delegatees, shall assume all obligations and responsibilities required under this section. The contractor shall assure compliance with the requirements of this section regardless of the entity providing the emergency services.

HISTORY

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

3. Amendment of subsections (a), (d)(1) and (g) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4 and 14454, Welfare and Institutions Code.