Md. Code Regs. 10.67.05.08

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.05.08 - Emergency Services Access

A. An MCO shall develop and maintain policies and procedures for the adequate provision of emergency services for all its enrollees, including:

(1) Instituting and monitoring a system for responding to enrollees' emergency medical conditions, with provisions for immediate attention to and appropriate disposition of emergency calls; and

(2) Informing and educating its enrollees in the procedures to be followed in the event of an emergency, whether within or outside of the MCO's service area.

B. An MCO shall provide medically necessary emergency services 24 hours per day, 7 days per week.

C. An MCO shall maintain an emergency telephone service, with a physician on call, for the purpose of rendering medical advice and authorizing care at other facilities when use of the MCO's own facilities is impractical.

D. An MCO may provide emergency services access through adequate and appropriate triage assessments performed by qualified medical professionals.

E. An MCO shall utilize the trauma triage and transfer protocols established through the Maryland Institute for Emergency Medical Services Systems (MIEMSS) as the basis for directing the severely injured enrollee to the most appropriate level designated trauma center.

F. An MCO shall reimburse, within 30 days of invoice, the undisputed claims of hospital emergency facilities and providers for the following services provided to the MCO's enrollees:

(1) Emergency services, as defined in COMAR 10.67.62.01B;

(2) Medical screening services based on the federal Emergency Medical Treatment and Active Labor Act (EMTALA);

(3) If the MCO authorized, referred, or otherwise instructed the enrollee to use the emergency facility, medically necessary services that are related to the emergency condition, including poststabilization services; and

(4) If the MCO fails to provide 24 hour access to a physician, medically necessary services that relate to the condition presented and that are provided by the provider in an emergency facility to the enrollee.

G. Poststabilization Services. The MCO may not require preapproval of, and is financially responsible for, poststabilization services obtained in or outside of the MCO's network and administered to maintain, improve, or resolve the enrollee's stabilized condition if:

(1) The MCO does not respond to a request for a preapproval within 1 hour;

(2) The MCO cannot be contacted; or

(3) The MCO representative and the treating physician cannot reach an agreement concerning the enrollee's care, and an MCO physician is not available for consultation, in which case:

(a) The MCO shall give the treating physician the opportunity to consult with an MCO physician; and

(b) The treating physician may continue care of the patient until a plan is reached or one of the following criteria is met:

(i) An MCO physician with privileges at the treating hospital assumes responsibility for the enrollee's care;

(ii) An MCO physician assumes responsibility for the enrollee's care through transfer;

(iii) An MCO representative and the treating physician reach an agreement concerning the enrollee's care; or

(iv) The enrollee is discharged.

H. An MCO may require that any continuing care be obtained from the MCO's providers or from providers approved by the MCO when the following conditions are satisfied:

(1) The enrollee's medical condition is appropriately stabilized and permits transferring responsibility for the enrollee's care, without medically harmful consequences, to these providers; and

(2) The transfer is consistent with the requirements of the federal Emergency Medical Treatment and Active Labor Act (EMTALA).

Md. Code Regs. 10.67.05.08

Regulations .08 recodified from 10.09.66.08 effective 46:22 Md. R. 976, eff. 11/1/2019