2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9431 - Emergency services

(a) When conducting utilization review or making a benefit determinations for emergency services, a health insurance organization or issuer shall comply with the provisions of this section.
(b) A health insurance organization or issuer shall cover emergency services necessary to screen and stabilize a covered person or enrollee in accordance with the following rules:
(1) A health insurance organization or issuer shall not require prior authorization for the emergency services described in subsection B above [sic], even if the emergency services are provided by a provider out of the health insurance organization or issuer's network (hereinafter, “non-participating provider”).
(2) If the emergency services are provided by a non-participating provider, no administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers shall be imposed.
(c)
(1) If the emergency services are provided by a participating provider, such services shall be subject to the applicable copayment, coinsurance, and deductible.
(2)
(A) If the emergency services are provided by a non- participating provider such services shall be subject to the same applicable copayment, coinsurance, and deductible, as if such services were provided by a participating provider.
(B) The covered person or enrollee shall not be required to pay any amount in excess of the applicable copayment, coinsurance and deductibles pursuant to the preceding paragraph.
(C) A health insurance organization or issuer meets the payment requirements of this section, if it provides payment of emergency services provided by a non-participating provider at a rate not less than the greater of the following:
(i) The rate negotiated with participating providers for emergency services, excluding any copayment or coinsurance imposed with respect to the covered person or enrollee.
(ii) The rate attributable to the emergency service provided, calculated using the same method the health insurance organization or issuer uses to determine payments for non-participating providers, but using the copayment, coinsurance and deductibles applicable to participating providers for the same services in lieu of the copayment, coinsurance and deductibles of non-participating providers.
(iii) The rate that would be paid under Medicare for the emergency services, excluding any copayment or coinsurance requirement applicable to participating providers.
(D)
(i) In the case of health plans with capitation or any other payment method that do not have a negotiated per-service rate for participating providers, the provisions of paragraph (C)(i) of this clause shall not apply.
(ii) If the health plan has more than one negotiated rate for a particular emergency service provided by participating providers, the amount referred to in paragraph (C)(i) of this clause is the median of such negotiated rates.
(3)
(A) Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible, may be imposed with respect to emergency services provided by non-participating providers to the extent such cost-sharing requirements generally apply to other services provided by non- participating providers.
(B) A deductible may be imposed with respect to emergency services provided by non-participating providers only as part of deductibles that generally apply to benefits or services provided by non-participating providers.
(d) To facilitate the review, for post-evaluation or post-stabilization services that a covered person or enrollee may require immediately, a health insurance organization or issuer shall provide access to a designated representative twenty-four (24) hours a day, seven (7) days a week.
History —Aug. 29, 2011, No. 194, added as § 24.110 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.