20-2803

20-2803. Emergency services access; prior
authorization; requirements

A. A health care services plan shall provide coverage for an initial medical
screening examination and any immediately necessary stabilizing treatment required by the
emergency medical treatment and active labor act (P.L. 99-272; 100 Stat. 164; 42 United
States Code section 1395dd) without prior authorization by the plan, subject to
applicable copayments, coinsurance and deductibles.

B. A health care services plan shall provide coverage for emergency ambulance
services without prior authorization, subject to applicable copayment, coinsurance and
deductibles.

C. A provider shall not deny, limit or otherwise restrict a patient's access to
medically necessary emergency services based on the patient's enrollment in a health care
services plan.

D. A health care services plan may require as a condition of coverage prior
authorization for health care services arising after the initial medical screening
examination and immediately necessary stabilizing treatment. Prior authorization is
granted unless denied or direction of the enrollee's care is initiated by the plan within
a reasonable period of time after the plan receives the prior authorization request. If
direction of care instructions are received from the plan after more than a reasonable
period of time has elapsed, the treating provider or providers shall comply with the late
instructions to the extent feasible, except that a health care services plan remains
responsible for coverage of medically necessary care given and substantially completed
before the late instructions were received.

E. A health care services plan that requires prior authorization under subsection C
shall provide twenty-four hour access by telephone or facsimile for enrollees and
providers to request prior authorization for medically necessary care after the initial
medical screening examination and any immediately necessary stabilizing treatment. Plan
personnel shall have access to a physician when necessary to make determinations
regarding prior authorization.

F. A health care services plan that gives prior authorization for specific care by
a provider shall not rescind or modify the authorization after the provider renders the
authorized care in good faith and pursuant to the authorization.

G. A hospital emergency department shall make reasonable efforts to promptly
contact the health care services plan for prior authorization for continuing treatment,
specialty consultations, transfer arrangements or other appropriate care for an
enrollee. A health care services plan shall not deny coverage for emergency services
provided to the plan's enrollee due to a provider's failure to obtain prior authorization
from the plan if the provider could not determine the patient's enrollment in a
particular plan due to the patient's physical condition, or if the patient's enrollment
information was not available from the plan at the time of the provider's contact.

H. If the health care services plan and the provider disagree on the medical
necessity of specific emergency services for an enrollee, except for emergency services
provided outside the geographic service area of the plan, medical personnel representing
the plan shall make necessary arrangements to assume the care of the enrollee within a
reasonable period of time after the disagreement arises. If the health care services
plan fails to assume the care of the enrollee as provided by this subsection, the plan
shall not deny coverage for medically necessary emergency services provided to the
enrollee due to lack of prior authorization.

I. If within a reasonable period of time after receiving a request from a hospital
emergency department for a specialty consultation a health care services plan fails to
identify an appropriate specialist who is available and willing to assume the care of the
enrollee, the emergency department may arrange for medically necessary emergency services
by any appropriate specialist, and the plan shall not deny coverage for these services
due to lack of prior authorization. A health care services plan shall not require prior
authorization for specialty care emergency services for treatment of any immediately life
threatening medical condition.