Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3229.Prior authorization requirements for emergency medical treatment;duties and responsibilities of organization, enrollees and participatingproviders; resolution of disputes.(a) A health maintenance organization that requires priorauthorization before making payment for the treatment of medical emergencyconditions, as defined by the health maintenance organization, shall provideenrollees with a toll-free telephone number answered 24 hours per day, sevendays a week. At least one person with medical training who is authorized todetermine whether an emergency condition exists shall be available 24 hours perday, seven days a week to make these determinations.
(b) A health maintenance organization shall not base its denial of paymentfor emergency medical services solely on the failure of the enrollee to receiveauthorization prior to receiving the emergency medical service. The enrolleemust notify the health maintenance organization of receipt of medical servicesfor emergency conditions within 24 hours or as soon after that as isreasonably possible. Nothing shall require the health maintenance organizationto authorize payment for any services provided during that 24 hour period,regardless of medical necessity, if those services do not otherwise constitutebenefits under the certificate of coverage approved by the commissioner.
(c) If the participating provider is responsible for seeking priorauthorization from the health maintenance organization before receiving paymentfor the treatment of emergency medical conditions and the enrollee is eligibleat the time when covered services are provided, then the enrollee will not beheld financially responsible for payment for covered services if the priorauthorization for emergency medical services has not been sought and received,other than for what the enrollee would otherwise be responsible, such ascopayments and deductibles.
(d) All disputes between an enrollee and a health maintenance organizationarising under the provisions of this section shall be resolved by means of thegrievance procedures established by the health maintenance organization.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3229.Prior authorization requirements for emergency medical treatment;duties and responsibilities of organization, enrollees and participatingproviders; resolution of disputes.(a) A health maintenance organization that requires priorauthorization before making payment for the treatment of medical emergencyconditions, as defined by the health maintenance organization, shall provideenrollees with a toll-free telephone number answered 24 hours per day, sevendays a week. At least one person with medical training who is authorized todetermine whether an emergency condition exists shall be available 24 hours perday, seven days a week to make these determinations.
(b) A health maintenance organization shall not base its denial of paymentfor emergency medical services solely on the failure of the enrollee to receiveauthorization prior to receiving the emergency medical service. The enrolleemust notify the health maintenance organization of receipt of medical servicesfor emergency conditions within 24 hours or as soon after that as isreasonably possible. Nothing shall require the health maintenance organizationto authorize payment for any services provided during that 24 hour period,regardless of medical necessity, if those services do not otherwise constitutebenefits under the certificate of coverage approved by the commissioner.
(c) If the participating provider is responsible for seeking priorauthorization from the health maintenance organization before receiving paymentfor the treatment of emergency medical conditions and the enrollee is eligibleat the time when covered services are provided, then the enrollee will not beheld financially responsible for payment for covered services if the priorauthorization for emergency medical services has not been sought and received,other than for what the enrollee would otherwise be responsible, such ascopayments and deductibles.
(d) All disputes between an enrollee and a health maintenance organizationarising under the provisions of this section shall be resolved by means of thegrievance procedures established by the health maintenance organization.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3229.Prior authorization requirements for emergency medical treatment;duties and responsibilities of organization, enrollees and participatingproviders; resolution of disputes.(a) A health maintenance organization that requires priorauthorization before making payment for the treatment of medical emergencyconditions, as defined by the health maintenance organization, shall provideenrollees with a toll-free telephone number answered 24 hours per day, sevendays a week. At least one person with medical training who is authorized todetermine whether an emergency condition exists shall be available 24 hours perday, seven days a week to make these determinations.
(b) A health maintenance organization shall not base its denial of paymentfor emergency medical services solely on the failure of the enrollee to receiveauthorization prior to receiving the emergency medical service. The enrolleemust notify the health maintenance organization of receipt of medical servicesfor emergency conditions within 24 hours or as soon after that as isreasonably possible. Nothing shall require the health maintenance organizationto authorize payment for any services provided during that 24 hour period,regardless of medical necessity, if those services do not otherwise constitutebenefits under the certificate of coverage approved by the commissioner.
(c) If the participating provider is responsible for seeking priorauthorization from the health maintenance organization before receiving paymentfor the treatment of emergency medical conditions and the enrollee is eligibleat the time when covered services are provided, then the enrollee will not beheld financially responsible for payment for covered services if the priorauthorization for emergency medical services has not been sought and received,other than for what the enrollee would otherwise be responsible, such ascopayments and deductibles.
(d) All disputes between an enrollee and a health maintenance organizationarising under the provisions of this section shall be resolved by means of thegrievance procedures established by the health maintenance organization.
