Section 1300.71.4 - Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services (California Code of Regulations)

§ 1300.71.4. Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services

The following rules set forth emergency medical condition and post-stabilization responsibilities for medically necessary health care services after stabilization of an emergency medical condition and until an enrollee can be discharged or transferred. These rules do not apply to a specialized health care service plan contract that does not provide for medically necessary health care services following stabilization of an emergency condition.

(a) Prior to stabilization of an enrollee's emergency medical condition, or during periods of destabilization (after stabilization of an enrollee's emergency medical condition) when an enrollee requires immediate medically necessary health care services, a health care service plan shall pay for all medically necessary health care services rendered to an enrollee.

(b) In the case when an enrollee is stabilized but the health care provider believes that the enrollee requires additional medically necessary health care services and may not be discharged safely, the following applies:

(1) A health care service plan shall approve or disapprove a health care provider's request for authorization to provide necessary post-stabilization medical care within one half hour of the request.

(2) If a health care service plan fails to approve or disapprove a health care provider's request for authorization to provide necessary post-stabilization medical care within one half-hour of the request, the necessary post-stabilization medical care shall be deemed authorized. Notwithstanding the foregoing sentence, the health care service plan shall have the authority to disapprove payment for (A) the delivery of such necessary post-stabilization medical care or (B) the continuation of the delivery of such care; provided, that the health care service plan notifies the provider prior to the commencement of the delivery of such care or during the continuation of the delivery of such care (in which case, the plan shall not be obligated to pay for the continuation of such care from and after the time it provides such notice to the provider, subject to the remaining provisions of this paragraph) and in both cases the disruption of such care (taking into account the time necessary to effect the enrollee's transfer or discharge) does not have an adverse impact upon the efficacy of such care or the enrollee's medical condition.

(3) Notwithstanding the provisions of subsection (b) of this rule, a health care service plan shall pay for all medically necessary health care services provided to an enrollee which are necessary to maintain the enrollee's stabilized condition up to the time that the health care service plan effectuates the enrollee's transfer or the enrollee is discharged.

(c) In the case where a plan denies the request for authorization of post-stabilization medical care and elects to transfer an enrollee to another health care provider, the following applies:

(1) When a health care service plan responds to a health care provider's request for post-stabilization medical care authorization by informing the provider of the plan's decision to transfer the enrollee to another health care provider, the plan shall effectuate the transfer of the enrollee as soon as possible,

(2) A health care service plan shall pay for all medically necessary health care services provided to an enrollee to maintain the enrollee's stabilized condition up to the time that the health care service plan effectuates the enrollee's transfer.

(d) All requests for authorizations, and all responses to such requests for authorizations, of post-stabilization medically necessary health care services shall be fully documented. All provision of medically necessary health care services shall be fully documented. Documentation shall include, but not be limited to, the date and time of the request, the name of the health care provider making the request, and the name of the plan representative responding to the request.

(1. New section filed 5-9-95 as an emergency; operative 5-9-95 (Register 95, No. 19). A Certificate of Compliance must be transmitted to OAL by 9-6-95 or emergency language will be repealed by operation of law on the following day. 2. New section refiled 9-5-95 as an emergency; operative 9-6-95 (Register 95, No. 36). A Certificate of Compliance must be transmitted to OAL by 1-4-96 or emergency language will be repealed by operation of law on the following day. 3. New section refiled 12-19-95 as an emergency; operative 1-4-96 (Register 95, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-17-96 or emergency language will be repealed by operation of law on the following day. 4. Certificate of Compliance, including amendment of section and Note, transmitted to OAL 3-7-96 and filed 4-11-96 (Register 96, No. 15). 5. Editorial correction of first paragraph and subsections (b)(2), (c) and (c)(1) (Register 96, No. 23). 6. Editorial correction of first paragraph (Register 99, No. 26). 7. Amendment filed 6-24-99 as an emergency; operative 6-24-99 (Register 99, No. 26). A Certificate of Compliance must be transmitted to OAL by 10-22-99 or emergency language will be repealed by operation of law on the following day. 8. Certificate of Compliance as to 6-24-99 order transmitted to OAL 9-30-99 and filed 11-8-99 (Register 99, No. 46).)

Note: Authority cited: Sections 1344 and 1371.4(g) and (h), Health and Safety Code. Reference: Sections 1317.1 and 1371.4, Health and Safety Code.

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