California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.71.4 - Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following rules set forth emergency medical condition
					 and post-stabilization responsibilities for medically necessary health care
					 services after stabilization of an emergency medical condition and until an
					 enrollee can be discharged or transferred. These rules do not apply to a
					 specialized health care service plan contract that does not provide for
					 medically necessary health care services following stabilization of an
					 emergency condition.
(a) Prior to
				  stabilization of an enrollee's emergency medical condition, or during periods
				  of destabilization (after stabilization of an enrollee's emergency medical
				  condition) when an enrollee requires immediate medically necessary health care
				  services, a health care service plan shall pay for all medically necessary
				  health care services rendered to an enrollee.
(b) In the case when an enrollee is
				  stabilized but the health care provider believes that the enrollee requires
				  additional medically necessary health care services and may not be discharged
				  safely, the following applies:
(1) A health
				  care service plan shall approve or disapprove a health care provider's request
				  for authorization to provide necessary post-stabilization medical care within
				  one half hour of the request.
(2)
				  If a health care service plan fails to approve or disapprove a health care
				  provider's request for authorization to provide necessary post-stabilization
				  medical care within one half-hour of the request, the necessary
				  post-stabilization medical care shall be deemed authorized. Notwithstanding the
				  foregoing sentence, the health care service plan shall have the authority to
				  disapprove payment for (A) the delivery of such necessary post-stabilization
				  medical care or (B) the continuation of the delivery of such care; provided,
				  that the health care service plan notifies the provider prior to the
				  commencement of the delivery of such care or during the continuation of the
				  delivery of such care (in which case, the plan shall not be obligated to pay
				  for the continuation of such care from and after the time it provides such
				  notice to the provider, subject to the remaining provisions of this paragraph)
				  and in both cases the disruption of such care (taking into account the time
				  necessary to effect the enrollee's transfer or discharge) does not have an
				  adverse impact upon the efficacy of such care or the enrollee's medical
				  condition.
(3) Notwithstanding the
				  provisions of subsection (b) of this rule, a health care service plan shall pay
				  for all medically necessary health care services provided to an enrollee which
				  are necessary to maintain the enrollee's stabilized condition up to the time
				  that the health care service plan effectuates the enrollee's transfer or the
				  enrollee is discharged.