28 CA ADC § 1300.71.4
28 CCR s 1300.71.4
Cal. Admin. Code tit. 28, s 1300.71.4
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 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.
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.
HISTORY
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).
28 CA ADC s 1300.71.4
END OF DOCUMENT
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