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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176G HEALTH MAINTENANCE ORGANIZATIONS
  • Section 5 Emergency services provided to members for emergency medical conditions

Section 5. (a) As used in this section, the following words shall have the following meanings:-

“Attending physician”, the emergency physician or consultant physician who actively treats the emergency medical condition of a member at an emergency facility.

“Emergency medical condition”, a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of a member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).

“Stabilization for discharge”, an emergency medical condition shall be deemed to be stabilized for purposes of discharging a member, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the member has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the member is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.

“Stabilization for transfer”, an emergency medical condition shall be deemed to be stabilized for transfer if a member can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the member is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.

(b) A health maintenance organization shall cover emergency services provided to members for emergency medical conditions. After the member has been stabilized for discharge or transfer, the health maintenance organization or its designee may require a hospital emergency department to contact the physician on-call designated by the health maintenance organization or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the health maintenance organization or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the health maintenance organization or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and a covered benefit under the member’s evidence of coverage. Consistent with the foregoing, a health maintenance organization may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.

(c) A health maintenance organization may require a member to contact either the health maintenance organization or its designee or the primary care provider of the member within 48 hours of receiving such emergency services, but notification already given to the health maintenance organization or to said primary care provider by the attending physician shall satisfy the requirements of this paragraph.

(d) Nothing in this section shall be construed to limit retrospective utilization review activities by a health maintenance organization with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, the health maintenance organization shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.

(e) A health maintenance organization shall clearly state in its brochures, contracts, policy manuals and printed materials that members shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever an enrollee is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No member shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of an emergency medical condition.

(f) A health maintenance organization shall provide or arrange for indemnity payments to a member or provider for a reasonable amount charged for the cost of emergency medical services by a provider who is not normally affiliated with the health maintenance organization when the member requires services for an emergency medical condition. Said indemnity payment under this section shall not be subject to the insurance laws of the commonwealth.

No contract between a participating provider of health care services and a health maintenance organization shall be issued or delivered in the commonwealth unless it contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the provider of health care services, the health maintenance organization shall (i) make payments for such services provided, (ii) notify the provider in writing of the reason or reasons for nonpayment, or (iii) notify the provider in writing of what additional information or documentation is necessary to complete said forms for such reimbursement. If the health maintenance organization fails to comply with this paragraph for any claims related to the provision of health care services, said health maintenance organization shall pay, in addition to any reimbursement for health care services provided, interest on such benefits, which shall accrue beginning 45 days after the health maintenance organization’s receipt of request for reimbursement at the rate of 1.5 per cent per month, not to exceed 18 per cent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim that the health maintenance organization is investigating because of suspected fraud.