§ 19-712.5. Reimbursement for hospital emergency facility and provider.
(a) Medically necessary services - Authorization by health maintenance organization.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services provided to a member or subscriber of the health maintenance organization if the health maintenance organization authorized, directed, referred, or otherwise allowed the member or subscriber to use the emergency facility and the medically necessary services are related to the condition for which the member was allowed to use the emergency facility.
(b) Medically necessary services - Failure to provide 24-hour access.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to a member or subscriber of the health maintenance organization if the health maintenance organization fails to provide 24-hour access in accordance with the standards of quality of care required under § 19-705.1 (b) (2) of this subtitle.
(c) Medical screening services pursuant to federal act.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medical screening, assessment, and stabilization services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act.
(d) Prior authorization or approval for payment.- Notwithstanding any other provision of this subtitle, a provider may not be required to obtain prior authorization or approval for payment from a health maintenance organization in order to obtain reimbursement under subsection (a), (b), or (c) of this section.
(e) Payments from member or subscriber for nonemergency.- Notwithstanding any other provision of this article, a hospital emergency facility or provider or a health maintenance organization that has reimbursed a provider may collect or attempt to collect payment from a member or subscriber for health care services provided for a medical condition that is determined not to be an emergency as defined in § 19-701 (e) of this subtitle.
(f) Follow-up care.- If a health maintenance organization authorizes, directs, refers, or otherwise allows a member or subscriber to access a hospital emergency facility or other urgent care facility for a medical condition that requires emergency surgery, the health maintenance organization:
(1) Shall reimburse the physician, oral surgeon, periodontist, or podiatrist, who performed the surgical procedure, for follow-up care that is:
(i) Medically necessary;
(ii) Directly related to the condition for which the surgical procedure was performed; and
(iii) Provided in consultation with the member's or subscriber's primary care physician; and
(2) May not impose on the member or subscriber any co-payment or other cost-sharing requirement for any follow-up care that exceeds what a member or subscriber is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the provider panel of the health maintenance organization.
§ 19-712.5. Reimbursement for hospital emergency facility and provider.
(a) Medically necessary services - Authorization by health maintenance organization.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services provided to a member or subscriber of the health maintenance organization if the health maintenance organization authorized, directed, referred, or otherwise allowed the member or subscriber to use the emergency facility and the medically necessary services are related to the condition for which the member was allowed to use the emergency facility.
(b) Medically necessary services - Failure to provide 24-hour access.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to a member or subscriber of the health maintenance organization if the health maintenance organization fails to provide 24-hour access in accordance with the standards of quality of care required under § 19-705.1 (b) (2) of this subtitle.
(c) Medical screening services pursuant to federal act.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medical screening, assessment, and stabilization services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act.
(d) Prior authorization or approval for payment.- Notwithstanding any other provision of this subtitle, a provider may not be required to obtain prior authorization or approval for payment from a health maintenance organization in order to obtain reimbursement under subsection (a), (b), or (c) of this section.
(e) Payments from member or subscriber for nonemergency.- Notwithstanding any other provision of this article, a hospital emergency facility or provider or a health maintenance organization that has reimbursed a provider may collect or attempt to collect payment from a member or subscriber for health care services provided for a medical condition that is determined not to be an emergency as defined in § 19-701 (e) of this subtitle.
(f) Follow-up care.- If a health maintenance organization authorizes, directs, refers, or otherwise allows a member or subscriber to access a hospital emergency facility or other urgent care facility for a medical condition that requires emergency surgery, the health maintenance organization:
(1) Shall reimburse the physician, oral surgeon, periodontist, or podiatrist, who performed the surgical procedure, for follow-up care that is:
(i) Medically necessary;
(ii) Directly related to the condition for which the surgical procedure was performed; and
(iii) Provided in consultation with the member's or subscriber's primary care physician; and
(2) May not impose on the member or subscriber any co-payment or other cost-sharing requirement for any follow-up care that exceeds what a member or subscriber is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the provider panel of the health maintenance organization.
§ 19-712.5. Reimbursement for hospital emergency facility and provider.
(a) Medically necessary services - Authorization by health maintenance organization.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services provided to a member or subscriber of the health maintenance organization if the health maintenance organization authorized, directed, referred, or otherwise allowed the member or subscriber to use the emergency facility and the medically necessary services are related to the condition for which the member was allowed to use the emergency facility.
(b) Medically necessary services - Failure to provide 24-hour access.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to a member or subscriber of the health maintenance organization if the health maintenance organization fails to provide 24-hour access in accordance with the standards of quality of care required under § 19-705.1 (b) (2) of this subtitle.
(c) Medical screening services pursuant to federal act.- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medical screening, assessment, and stabilization services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act.
(d) Prior authorization or approval for payment.- Notwithstanding any other provision of this subtitle, a provider may not be required to obtain prior authorization or approval for payment from a health maintenance organization in order to obtain reimbursement under subsection (a), (b), or (c) of this section.
(e) Payments from member or subscriber for nonemergency.- Notwithstanding any other provision of this article, a hospital emergency facility or provider or a health maintenance organization that has reimbursed a provider may collect or attempt to collect payment from a member or subscriber for health care services provided for a medical condition that is determined not to be an emergency as defined in § 19-701 (e) of this subtitle.
(f) Follow-up care.- If a health maintenance organization authorizes, directs, refers, or otherwise allows a member or subscriber to access a hospital emergency facility or other urgent care facility for a medical condition that requires emergency surgery, the health maintenance organization:
(1) Shall reimburse the physician, oral surgeon, periodontist, or podiatrist, who performed the surgical procedure, for follow-up care that is:
(i) Medically necessary;
(ii) Directly related to the condition for which the surgical procedure was performed; and
(iii) Provided in consultation with the member's or subscriber's primary care physician; and
(2) May not impose on the member or subscriber any co-payment or other cost-sharing requirement for any follow-up care that exceeds what a member or subscriber is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the provider panel of the health maintenance organization.
