Rule 120-2-80-.06 - Emergency Services, Stabilization(1) As used in this section, the term "emergency services" or "emergency condition" shall have the same meaning as set forth in O.C.G.A. § 33-20A-3(2).(2) No managed care plan may require, as a condition of receiving emergency services, that a covered person seek prospective authorization. This prohibition against prior authorization extends to such time as the covered person is stabilized for such emergency condition.(3) A managed care entity shall include provisions in its managed care plans describing: (a) Coverage for emergency services;(b) Any out of pocket, copayment, or other expenses which may accrue to a covered person;(c) Provisions for out of network and out of service area emergency services;(d) The terms "authorization" or "prospective authorization" as they relate to the covered person, including how such authorization procedures will apply and be administered if sought by the covered person in an emergency even though not required; and(e) A covered person's or provider's review or appeal rights in accordance with O.C.G.A. Title 33, Chapter 46 and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58, in the event that the managed care entity does not pay for emergency services obtained by the covered person.(4) A managed care entity shall include provisions in its provider contracts defining and describing prospective authorization or other authorization as they relate to a contracting or participating provider.(5) A managed care entity which authorizes the delivery of emergency services for evaluation, diagnostic testing or treatment provided as a part of intervention, whether for evaluation or stabilization purposes, shall not subsequently deny payment in accordance with the coverage of the managed care plan.(6) A managed care entity may review delivery of emergency services for purposes of payment or reimbursement only if: (a) there is reason to believe, pursuant to subsequent evidence, such services were not medically necessary nor appropriate in accordance with established medical criteria and the requirements of Title 33, Chapter 46 and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58; or(b) the individual receiving such care should have known, as a prudent layperson, possessing an average knowledge of medicine and health, that an emergency medical condition did not exist.(7) If a participating provider or other authorized representative of a managed care entity authorizes emergency services as permitted by the terms of the managed care plan or the terms of the provider contract, the managed care entity shall not subsequently review such emergency services for purposes of payment or reimbursement or retract its authorization after the emergency services have been provided, unless the authorization was based on a material misrepresentation about the covered person's health condition which was made by the covered person or the provider of emergency services.Ga. Comp. R. & Regs. R. 120-2-80-.06
O.C.G.A. Secs. 33-2-9, 33-20A-2, 33-20A-4, 33-20A-5, 33-20A-9, 33-46-2, 33-46-4.
Original Rule entitled "Emergency Services, Stabilization" adopted. F. Mar. 20, 1998; eff. Apr. 9, 1998.