Rule 120-2-106-.05 - Emergency Services(1) Insurers shall pay covered emergency medical services for covered persons regardless of whether the provider or facility is participating or non-participating in their network according to this Regulation. Such an insurer shall make such payment without prior authorization and without retrospective payment denial for emergency medical services deemed to be medically necessary.(2) If a covered person receives emergency medical services from a non-participating provider, such person shall not be liable to the non-participating provider or facility for any amount exceeding such person's deductible, coinsurance, copayment, or other cost-sharing amount as determined by such person's policy. The amount payable by an insurer for emergency medical services paid directly to the provider shall be the greater of: (a) The verifiable median contracted amount paid by all eligible insurers for similar services calculated by a vendor utilized and chosen by the Commissioner;(b) The most recent verifiable amount agreed to by the insurer and the non-participating emergency medical provider for the same services during which time the provider was in-network with the insurer; (if applicable)(c) A higher amount as the insurer may deem appropriate given the complexity and circumstances of the services provided. Any amount payable by an insurer under this section for emergency medical services shall not include any amount of coinsurance, copayment, or deductible owed by the covered person or already paid by such person.
(3) Insurers shall not deny benefits or emergency medical services rendered based on a covered person's failure to provide subsequent notification where the insured's medical condition prevented timely notification.(4) Emergency medical services received from non-participating providers and/or facilities shall count toward the deductible and any maximum out of pocket policy provisions as if the services were obtained from a participating provider.(5) In cases of emergency medical services received from a non-participating facility, the facility shall bill the covered person no more than deductible, coinsurance, copayment, or other cost-sharing as determined by such person's policy.(6) Insurer payments made to providers in this Code section shall be in accord with prompt payment requirements under 33-24-59.14. Notification should reflect whether coverage is subject to the exclusive jurisdiction of ERISA (1974), U.S.C. Sec 1001.Ga. Comp. R. & Regs. R. 120-2-106-.05
O.C.G.A. §§ 33-2-9, 33-20E.
Original Rule entitled "Emergency Services" adopted. F. Dec. 7, 2020; eff. Jan. 1, 2021, as specified by the Agency.