40-4603. Same; emergency services, prohibitions on health care plan; prior authorization after condition stabilized; post evaluation or post stabilization services.
40-4603
40-4603. Same; emergency services, prohibitions on health care plan; priorauthorization after condition stabilized; post evaluation or post stabilizationservices.(a) A health benefit plan shall not deny coverage foremergencyservices if the symptoms presented by an insured and recorded by theattending provider indicate that an emergency medical condition exists,or for emergency services necessary to provide an insured with a medicalexamination andstabilizing treatment,regardless of whether prior authorization was obtained to provide thoseservices.
(b) If a participating provider or other authorized representative of ahealth insurer authorizes emergency services, the health insurer shall notsubsequently rescind or modify that authorization after the provider rendersthe authorized care in good faith and pursuant to the authorization except for:
(1) Payments made as a result of misrepresentation, fraud, omission orclerical error; and
(2) copayment, coinsurance or deductible amounts that are the responsibilityof the insured.
(c) Once an insured is stabilized pursuant to subsection (a), ahealth benefit plan may require as a condition of further coverage that ahospitalemergency facility shall promptly contact the health insurer for priorauthorization for continuing treatment, specialty consultations, transferarrangements or other medically necessary and appropriate care for an insured.
(d) Coverage of emergency services shall be subject to applicablecopayments, coinsurance and deductibles.
(e) For required post evaluation or post stabilization services immediatelyfollowing treatment of an emergency medical condition, a health insurer shallprovide access to an authorized representative 24 hours a day, seven days aweek.
History: L. 1997, ch. 190, § 18; July 1.