Common use of Emergency Care Clause in Contracts

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post- stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line.  A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post- stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line. ▪ A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-one- hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post- stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line.  A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to OMPP that it has a mechanism in place to be available to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. 3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise There is no emergency room services co-payment in Hoosier Healthwise.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  Where to submit medical records for prudent layperson review.  That the provider has 120 days to submit medical records for prudent layperson review.  The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent.  A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records.  A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. For dates of service after April 1, 2020 the MCE must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication. 3.6.1 Post-stabilization As described in 42 CFR 438.114(e), which relates to coverage and payment of post-stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to OMPP that it has a mechanism in place to be available to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. 3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise There is no emergency room services co-payment in Hoosier Healthwise.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line.  A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization As described in 42 CFR 438.114(e), which relates to coverage and payment of post-stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to OMPP that it has a mechanism in place to be available to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. 3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise There is no emergency room services co-payment in Hoosier Healthwise.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, condition unless the Contractor authorized this treatment. Effective February 1, 2020 2020, the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.will

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line. ▪ A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization As described in 42 CFR 438.114(e), which relates to coverage and payment of post-stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to OMPP that it has a mechanism in place to be available to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. 3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise There is no emergency room services co-payment in Hoosier Healthwise.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days7)- days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the-job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. The MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. The Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty-four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  Where to submit medical records for prudent layperson review.  That the provider has 120 days to submit medical records for prudent layperson review.  The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-post- stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours24)- hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  Where to submit medical records for prudent layperson review.  That the provider has 120 days to submit medical records for prudent layperson review.  The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)- hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours24)- hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)- hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at oneno more than the Medicaid fee-hundred percent for-service (100%FFS) rate per section 1932(b)(2)(D) of the Medicaid rate Social Security Act, unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility facilit y fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the- job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. The MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/Xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. The Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty-four (24) hours-a-day, seven (7) days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days7)- days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the-job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line.  A mechanism, policies and procedures for conducting prudent layperson reviews. 3.6.1 Post-stabilization

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent. ▪ A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records. ▪ A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. For dates of service after April 1, 2020 the MCE must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication. 3.6.1 Post-stabilization As described in 42 CFR 438.114(e), which relates to coverage and payment of post-stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to OMPP that it has a mechanism in place to be available to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. 3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise There is no emergency room services co-payment in Hoosier Healthwise.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at oneno more than the Medicaid fee-hundred percent for-service (100%FFS) rate per section 1932(b)(2)(D) of the Medicaid rate Social Security Act, unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the-job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. The MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/Xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. The Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB- 04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post- stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent. ▪ A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records. ▪ A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. The Contractor must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, condition unless the Contractor authorized this treatment. Effective February 1, 2020 2020, the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physicianphysic ian’s determination is binding binding, and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020, the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty-four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member has made a call to the Contractor’s 24- Hour Nurse Call Line twenty-four (24) hours prior to an ER visit, and to waive emergency

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” 15- standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto.ontractor of

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at oneno more than the Medicaid fee-hundred percent for-service (100%FFS) rate per section 1932(b)(2)(D) of the Medicaid rate Social Security Act, unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the- job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. The MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/Xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care provider. Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at one-hundred percent (100%) the Medicare rate or, if there is no Medicare rate, at 130% of the Medicaid rate unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit determine what constitutes an emergency on the basis of lists of diagnoses or symptoms. The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition. The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall will conduct a prudent layperson review to determine whether an emergency medical condition exists; , the reviewer must shall not have more than a high school education and must shall not have training in a medical, nursing or social work-related field. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services. The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific condition. 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. The physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. As part of readiness review, the Contractor shall demonstrate to OMPP that it has the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.

Emergency Care. The Contractor shall cover emergency services without the need for prior authorization or the existence of a contract with the emergency care providerprovider per 42 CFR 438.114(c)(1)(i). Services for treatment of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12-15-12 (i.e., subject to the “prudent layperson” standard), shall be available twenty twenty-four (24)-hours-a-day, seven (7)-days-a- a-week. The Contractor shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations at 42 CFR 489.24, which sets special responsibilities for hospitals in emergency cases, provided to a member who presents to an emergency department with an emergency medical condition. The Contractor shall also comply with all applicable emergency services requirements specified in IC 12-15-12. The Contractor shall reimburse out-of-network providers at oneno more than the Medicaid fee-hundred percent for-service (100%FFS) rate per section 1932(b)(2)(D) of the Medicaid rate Social Security Act, unless other payment arrangements are made. The Contractor is required to reimburse for the medical screening examination and facility fee for the screening but is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the Contractor authorized this treatment. Effective February 1, 2020 the The Contractor shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent. In accordance with 42 CFR 438.114, which relates to emergency and post-stabilization services, the Contractor may not limit what constitutes an emergency on the basis of lists of diagnoses or symptomssymptoms per 42 CFR 438.114(d)(1)(i). The Contractor may not deny payment for treatment obtained when a member had an emergency medical condition, even if the outcomes, in the absence of immediate medical attention, would not have been those specified in the definition of emergency medical condition, and may not deny payment for treatment obtained when a representative of the Contractor instructs the enrollee to seek emergency services per 42 CFR 438.114(c)(1)(ii)(A)-(B). The Contractor may not deny or pay less than the allowed amount for the CPT code on the claim without offering the provider the opportunity for a medical record review. The Contractor shall conduct a prudent layperson review to determine whether an emergency medical condition exists; the reviewer must not have more than a high school education and must not have training in a medical, nursing or social work-related field. A prudent layperson would no longer be qualified after an average of two (2) to three (3) years spent on the job due to the on-the- job medical training/experience and would require replacement. The Contractor is prohibited from refusing to cover emergency services if the emergency room provider, hospital or fiscal agent does not notify the member’s PMP or the Contractor of the member’s screening and treatment within ten (10) calendar days of presentation for emergency servicesservices per 42 CFR 438.114(d)(1)(ii). The member who has an emergency is not liable for the payment of subsequent screening and treatment that may be needed to diagnose or stabilize the specific conditioncondition per 42 CFR 438.114(d)(2). The Per 42 CFR 438.114(d)(3), 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. The In addition, the attending physician’s determination is binding and the Contractor may not challenge the determination. The Contractor shall comply with policies and procedures set forth the IHCP Provider Bulletin regarding Emergency Room Services Coverage dated May 21, 2009 (BT200913) and January 30, 2020 (BT202009), and any updates thereto. The MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/Xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. The Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: ▪ Where to submit medical records for prudent layperson review. ▪ That the provider has 120 days to submit medical records for prudent layperson review. ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty-four (24) hours-a-day, seven (7) days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent. ▪ A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records. ▪ A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. The Contractor must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication.