N.M. Code R. § 8.308.9.25 - EMERGENCY AND POST STABILIZATION SERVICES
A. In this section, emergency medical
condition means a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in the following:
(1) Placing the health of the individual (or,
for a pregnant individual, the health of the individual or their unborn child)
in serious jeopardy.
(2) Serious
impairment to bodily functions.
(3)
Serious dysfunction of any bodily organ or part.
B. In this section, emergency services means
covered inpatient and outpatient services as follows.
(1) Furnished by a provider that is qualified
to furnish these services under the federal rules. See
42 CFR
438.114.
(2) Needed to evaluate or stabilize an
emergency medical condition.
C. Post-stabilization care services means
covered services, related to an emergency medical condition that are provided
after a member is stabilized to maintain the stabilized condition, or, under
the circumstances described
42 CFR
438.114(e), to improve or
resolve the member's condition.
D.
The MCO is responsible for coverage and payment of emergency services and
post-stabilization care services. The MCO must cover and pay for emergency
services regardless of whether the provider that furnishes the services has a
contract with the MCO. The MCO may not deny payment for treatment obtained
under either of the following circumstances.
(1) A member had an emergency medical
condition, including cases in which the absence of immediate medical attention
would not have had the outcomes specified in the definition of emergency
medical condition in Subsection A of
8.308.9.24
NMAC.
(2) A representative of the
MCO instructs the member to seek emergency services.
E. The MCO may not:
(1) limit what constitutes an emergency
medical condition with reference to Subsection A of
8.308.9.24
NMAC on the basis of lists of diagnoses or symptoms; or
(2) refuse to cover emergency services based
on the emergency room provider or hospital not notifying the member's PCP or
the MCO.
F. A member who
has an emergency medical condition may not be held liable for payment of
subsequent screening and treatment needed to diagnose the specific condition or
stabilize the member.
G. The
attending emergency physician, or the provider actually treating the member, is
responsible for determining when the member is sufficiently stabilized for
transfer or discharge, and that determination is binding on the MCO that is
responsible for coverage and payment.
Notes
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