Cal. Code Regs. Tit. 22, § 53912.5 - Care Under Emergency Circumstances

(a) Each GMC plan shall meet the requirements specified in Section 53216.

(b) Each GMC plan shall arrange for and make payment, at the lowest of the Medi-Cal fee-for-service rate or the plan negotiated rate, for emergency services as defined in Section 51056.

(c) Each GMC plan shall make payment, at the lowest of the Medi-Cal fee-for-service rate or the plan negotiated rate, for the diagnostic portion of any emergency room or urgent care visit. Specifically, each plan shall reimburse and shall not require prior authorization for the following:

(1) Emergency room services required to determine whether a member's condition requires emergency services.

(2) All other capitated services, such as radiology or pathology, necessary to diagnose the possible emergency condition.

(d) A GMC plan may authorize and reimburse services provided beyond those required to determine whether the condition is an emergency.

Notes

Cal. Code Regs. Tit. 22, § 53912.5

1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15).

Note: Authority cited: Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Sections 14088.4, 14089 and 14454, Welfare and Institutions Code.

1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15).