§ 56216. Care Under Emergency Circumstances.

(a) Each PCCM plan shall provide information to members on obtaining medical services on a 24-hour-a-day, seven-days-a-week basis in the event of an emergency as defined in section 51056(a).

(b) Written procedures shall be developed and followed by the PCCM plan regarding care under emergency circumstances provided by nonplan providers in and outside the service area. These procedures shall include but shall not be limited to the following:

(1) Verification of membership.

(2) Transfer of medical management of the member to the PCCM plan.

(3) Payment for PCCM plan authorized services that are included in the PCCM contract as a covered service.

(4) Notice to nonplan providers of the right to:

(A) Dispute the PCCM plan's rejection or reduction of the claim.

(B) Submit the dispute to the Department for resolution in accordance with section 56262.

(c) When the course of treatment of a PCCM plan member under emergency services requires the use of drugs, the PCCM plan shall authorize the provider to furnish a sufficient quantity of drugs to last until the member can reasonably be expected to have a prescription filled.

HISTORY

1. New section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.

2. New section refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.

3. Request to readopt section on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).

5. New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.

6. Certificate of Compliance as to 3-25-91 order including amendment of subsections (a) and (c) transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).

Note

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14088, 14088.16, 14088.2 and 14088.4, Welfare and Institutions Code.