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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.