410-141-3840 Emergency and Urgent Care Services (1) CCOs shall have written policies, procedures, and monitoring systems that ensure the provision of appropriate urgent, emergency, and triage services 24-hours a day, 7-days-a-week for all members. CCOs shall: (a) Communicate these policies and procedures to participating providers; (b) Regularly monitor participating providers' compliance with these policies and procedures; and (c) Take any corrective action necessary to ensure compliance. CCOs shall document all monitoring and corrective action activities. (2) CCOs shall have written policies, procedures, and monitoring processes to ensure that a provider provides a medically or orally appropriate response as indicated to urgent or emergency calls including but not limited to the following: (a) Telephone or face-to-face evaluation of the member; (b) Capacity to conduct the elements of an assessment to determine the necessary interventions to begin stabilization; (c) Development of a course of action; (d) Provision of services and referral needed to begin post-stabilization care or provide outreach services in the case of a member requiring behavioral health services, or a member who cannot be transported or is homebound; (e) Provision for notifying a referral emergency room, when applicable, concerning the arriving member’s presenting problem, and whether or not the provider will meet the member at the emergency room; and (f) Provision for notifying other providers that prior authorization is required for post-stabilization care in accordance with this rule. (3) CCOs shall ensure the availability of an after-hours call-in system adequate to triage urgent care and emergency calls from members or a member’s long-term care provider or facility. The CCO representative shall return urgent calls appropriate to the member's condition but in no event more than 30 minutes after receipt. If information is not adequate to determine if the call is urgent, the CCO representative shall return the call within 60 minutes to fully assess the nature of the call. If information is adequate to determine that the call may be emergent in nature, the CCO shall return the call. (4) If emergency room screening examination leads to a clinical determination by the examining provider that an actual emergency medical condition exists under the prudent layperson standard, the CCO must pay for all services required to stabilize the patient, except as otherwise provided in section (6) of this rule. The CCO may not require prior authorization for emergency services: (a) The CCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergent; (b) The CCO may not limit what constitutes an emergency medical condition based on lists of diagnoses or symptoms; (c) The CCO may not deny a claim for emergency services merely because the PCP was not notified, or because the CCO was not timely billed for the service. (5) When a member's PCP, designated provider, or other CCO representative instructs the member to seek emergency care, whether for physical, behavioral, or dental services, whether in or out of the network, the CCO shall pay for the screening examination and other medically appropriate services. Except as otherwise provided in section (6) of this rule, the CCO shall pay for post-stabilization care that was: (a) Pre-authorized by the CCO; (b) Not pre-authorized by the CCO if the CCO, or the on-call provider, failed to respond to a request for pre-authorization within one hour of the request, or the member could not contact the CCO or provider on call; or (c) If the CCO and the treating provider cannot reach an agreement concerning the member's care and a CCO representative is not available for consultation, the CCO must give the treating provider the opportunity to consult with a CCO provider. The treating provider may continue with care of the member until a CCO provider is reached or one of the criteria is met. (6) The CCO’s responsibility for post-stabilization care it has not authorized ends when: (a) The participating provider with privileges at the treating hospital assumes responsibilities for the member's care; (b) The participating provider assumes responsibility for the member's care through transfer; (c) A CCO representative and the treating provider reach an agreement concerning the member's care; or (d) The member is discharged. (7) CCOs shall have methods for tracking inappropriate use of urgent and emergency care and shall take action, including individual member counseling, to improve appropriate use of urgent and emergency care services: (a) CCOs shall educate members about, and support them in, how to appropriately access care from emergency rooms, urgent care and walk-in clinics, non-traditional health care workers, and less intensive interventions other than their primary care home; (b) CCOs shall apply and employ innovative strategies to decrease unnecessary hospital utilization. (8) CCOs must limit charges to members for post-stabilization care services to an amount no greater than what the CCO would charge the member if he or she had obtained the services through the CCO. For purposes of cost sharing, post stabilization care services begin upon inpatient admission. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020