§ 9.672. Emergency services.
(a) A plan shall utilize the definition of ‘‘emergency service’’ in section 2102 of the act (40 P. S. § 991.2102) in administering benefits, adjudicating claims and processing complaints and grievances.
(b) A plan may not deny any claim for emergency services on the basis that the enrollee did not receive permission, prior approval, or referral prior to seeking emergency service.
(c) A plan shall apply the prudent layperson standard to the enrollee’s presenting symptoms and services provided in adjudicating related claims for emergency services.
(d) Coverage for emergency services provided during the period of the emergency, shall include evaluation, testing, and if necessary, stabilization of the condition of the enrollee, emergency transportation and related emergency care provided by a licensed ambulance service. Use of an ambulance as transportation to an emergency facility for a condition that does not satisfy the definition of ‘‘emergency service’’ does not constitute an emergency service and does not require coverage as an emergency service.
(e) A plan may not require an enrollee to utilize any particular emergency transportation services organization or a participating emergency transportation services organization for emergency care.
(f) The emergency health care provider shall notify the enrollee’s managed care plan of the provision of emergency services and the condition of the enrollee.
(g) If the enrollee is admitted to a hospital or other health care facility, the emergency health care provider shall notify the enrollee’s managed care plan of the emergency services delivered within 48 hours or on the next business day, whichever is later. An exception to this requirement will be made where the medical condition of the patient precludes the provider from accurately determining the identity of the enrollee’s managed care plan within 48 hours of admission.
(h) If the enrollee is not admitted to a hospital or other health care facility, the claim for reimbursement for emergency services provided shall serve as notice to the enrollee’s managed care plan of the emergency services provided by the emergency health care provider.
Cross References This section cited in 28 Pa. Code § 9.651 (relating to HMO provision and coverage of basic health services to enrollees).
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