Coverage and Payment of Emergency Services. The HMO must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The HMO may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the member’s primary care provider, or HMO of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The HMO in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO as identified in 42 CFR 438.114(b) as responsible for coverage and payment. Nothing in this requirement mandates the HMO to reimburse for non- authorized post-stabilization services. • The HMO shall provide emergency services consistent with 42 CFR 438.114. It is financially responsible for emergency services whether obtained within or outside the HMO’s network. This includes paying for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. • The HMO may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. • The HMO may not deny payment for emergency services for a member with an emergency medical condition (even if the absence of immediate medical attention would not have had the outcomes specified in paragraphs 1., 2. and 3. of part A of the definition of Emergency Medical Condition) or for a member who had HMO approval to seek emergency services. • The HMO may not deny payment based on the emergency room provider, hospital or fiscal agent not notifying the member’s primary care provider or the HMO of the member’s screening and treatment within ten (10) days of the member’s presentation for emergency services. • The member may not be held liable for payment of screening and treatment needed to diagnose the specific condition or stabilize the patient. • The treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO.
Coverage and Payment of Emergency Services a) The Contractor must cover and pay for Emergency Services regardless of whether the provider that furnishes the services has a contract with the Contractor.
b) The Contractor must advise Enrollees that they may access Emergency Services at any Emergency Services provider.
c) Prior authorization for treatment of an Emergency Medical Condition is never required. APPENDIX G October 1, 2005
d) The Contractor may not deny payment for treatment obtained in either of the following circumstances:
i) An Enrollee had an Emergency Medical Condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition above.
ii) A representative of the Contractor instructs the Enrollee to seek Emergency Services.
e) A Contractor may not:
i) limit what constitutes an Emergency Medical Condition based on lists of diagnoses or symptoms; or
ii) refuse to cover emergency room services based on the failure of the provider or the Enrollee to give the Contractor notice of the emergency room visit.
f) An Enrollee who has an Emergency Medical Condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.
g) The attending emergency physician, or the provider actually treating the Enrollee, is responsible for determining when the Enrollee is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor for payment.
Coverage and Payment of Emergency Services a) The Contractor must cover and pay for Emergency Services regardless of whether the provider that furnishes the services has a contract with the Contractor.
b) The Contractor shall cover and pay for services as follows:
i) Participating Providers
A) Payment by the Contractor for general hospital emergency department services provided to an Enrollee by a Participating Provider shall be at the rate or rates of payment specified in the contract between the Contractor and the hospital. Such contracted rate or rates shall be paid without regard to whether such services meet the definition of Emergency Medical Condition.
B) Payment by the Contractor for physician services provided to an Enrollee by a Participating Provider while the Enrollee is receiving general hospital emergency department services shall be at the rate or rates of payment specified in the contract between the Contractor and the physician. Such contracted rate or rates shall be paid without regard to whether such services meet the definition of Emergency Medical Condition.
Coverage and Payment of Emergency Services a) The Contractor must cover and pay for Emergency Services regardless of whether the provider that furnishes the services has a contract with the Contractor.
b) The Contractor shall cover and pay for services as follows:
