Cal. Code Regs. Tit. 22, § 53855 - Care Under Emergency Circumstances
(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,
(3) The rate negotiated between the plan and
the provider of services for emergency services as defined in section
51056.
(e) For emergency inpatient hospital
services, payment shall be made in accordance with the provisions in the
contract between the plan and the department.
(f) If disputes arise over claims submitted
by providers seeking reimbursement for the provision of emergency services to
plan members, the parties shall adhere to the procedures and requirements
prescribed in section
53875 for the resolution of such
disputes.
(g) In the event the
provision of emergency services to plan members is delegated to an entity, such
entity, and any further delegatees, shall assume all obligations and
responsibilities required under this section. The contractor shall assure
compliance with the requirements of this section regardless of the entity
providing the emergency services.
Notes
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (a), (d)(1) and (g) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4 and 14454, Welfare and Institutions Code.
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (a), (d)(1) and (g) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.