California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53855 - Care Under Emergency Circumstances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a designated region shall
					 cover emergency medical services without prior authorization pursuant to title
					 10, CCR, section
					 1300.67(g) and
					 title 22, CCR, section
					 53216. Each plan shall reimburse,
					 without prior authorization, hospital emergency departments or emergency
					 physicians for medical screening examinations necessary to determine the
					 presence or absence of an emergency medical condition and, if an emergency
					 medical condition exists, for all services medically necessary to stabilize the
					 plan member. If the medical screening examination indicates that the patient's
					 condition does not constitute an emergency as defined in section
					 51056, hospital emergency
					 departments or emergency physicians shall obtain prior authorization from the
					 plan to render treatment. The plan may deny reimbursement for any services
					 rendered to the member beyond the medical screening examination if the hospital
					 emergency department or emergency physician fails to obtain prior
					 authorization. Upon receipt of a request for such authorization from an
					 emergency services provider, a plan shall render a decision upon the request
					 within 30 minutes, or the request shall be deemed to be approved.
(b) Each plan shall maintain a 24-hour
					 multilingual telephone contact number for handling emergencies. Each plan shall
					 ensure that a physician is available 24 hours a day to: coordinate the transfer
					 to a plan provider of a member whose condition is stabilized; or authorize
					 medically necessary post-stabilization services. Each plan shall have a system
					 to ensure continuity of care and follow-up care for all plan members for whom
					 the plan has denied authorization for emergency services.
(c) A plan may subject all hospital emergency
					 department and emergency physician claims to post-service, prepayment review
					 for post-stabilization services; however claims for medical screening
					 examinations shall not be denied without review. Each plan shall pay emergency
					 services claims at the appropriate level based on the documentation submitted.
					 All properly documented claims for medical screening examinations and emergency
					 services rendered by noncontracted providers shall be paid by the plan within
					 45 days of receipt of a valid invoice. Each plan shall pay for all claims
					 involving medically necessary services to diagnose and treat nonemergency
					 conditions that the plan has prior authorized.
(d) Each plan shall arrange and make payment
					 for emergency department, emergency physician and emergency transportation
					 services, at the lesser of:
(1) The usual
					 charges made to the general public by the emergency services
					 provider,
(2) The maximum Medi-Cal
					 fee-for-service rate, as specified in sections
					 51503 and
					 51509, or
(3) The rate negotiated between the plan and
					 the provider of services for emergency services as defined in section
					 51056.