Cal. Code Regs. Tit. 22, § 53216 - Care Under Emergency Circumstances

(a) Each plan shall provide, directly or by subcontract, at least one physician and a nurse on duty 24 hours a day, 7 days a week, at each location designated as a location where members can obtain medical services in the event of emergency circumstances, as defined in Section 51056.

(b) Written procedures shall be developed and applied by the plan regarding care under emergency circumstances provided by nonplan providers in and outside the service area. These procedures shall include but not be limited to the following:

(1) Verification of membership.

(2) Transfer of the medical management of the member to a plan provider.

(3) Payment within 60 days of receipt of properly documented bills for the services rendered to the member. Bills for services rendered to the member shall be submitted not later than the second month following the month of service, except for good cause.

(4) Written notice of action within 60 days of receipt of bills which are denied or reduced for any reason by the plan. The notice shall include a statement, subject to prior approval by the Department, of the provider's right to:

(A) Dispute the plan's rejection or reduction of the bill.

(B) Submit the dispute to the Department pursuant to Article 7.

(c) The plan shall provide or pay for medical transportation, as defined in Sections 51151 and 51323, to members needing care when such transportation is necessary due to the medical condition of the member.

(d) Each provider who agrees with a plan to provide emergency medical services shall furnish, when the course of treatment of a plan member under emergency circumstances requires the use of drugs, a sufficient quantity of such drugs to last until the member can reasonably be expected to have a prescription filled.

Notes

Cal. Code Regs. Tit. 22, § 53216

1. Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No. 27).
2. Amendment of subsection (b) filed 6-12-79; effective thirtieth day thereafter (Register 79, No. 24).

Note: Authority cited: Sections 14312 and 14454, Welfare and Institutions Code. Reference: Section 14454, Welfare and Institutions Code.

1. Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No. 27).
2. Amendment of subsection (b) filed 6-12-79; effective thirtieth day thereafter (Register 79, No. 24).