N.J. Admin. Code § 11:24-5.3

Current through Register Vol. 56, No. 11, June 3, 2024

Section 11:24-5.3 - Emergency and urgent care services

(a) The HMO shall establish written policies and procedures governing the provision of emergency and urgent care which shall be distributed to each subscriber at the time of initial enrollment.

(b) Emergency and urgent care services shall include, but are not limited to:

1. Medical and psychiatric care, which shall be available 24 hours a day, seven days a week;

2. Coverage for trauma services at any designated Level I or II trauma center as medically necessary. Such coverage shall continue at least until, in the judgment of the attending physician, the member is medically stable, no longer requires critical care, and can be safely transferred to another facility. If the HMO requests transfer to a hospital participating in the HMO network, the transfer shall be effected in accordance with Federal regulations at 42 C.F.R. 489.20 and 489.24;

3. Coverage for out-of-service area medical care when medically necessary for urgent or emergency conditions where the member cannot reasonably access in-network services;

4. Prehospital care and hospital services regardless of location when medically necessary for injury or emergency illness; and

5. Upon a member's arrival in a hospital, coverage of a medical screening examination, as required by the Federal Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, and as specified in N.J.A.C. 8:43G-12.

(c) With respect to services provided pursuant to (b)2 or 5 above, carriers shall reimburse hospitals and physicians for all medically necessary emergency and urgent health care services covered under the health benefits plan, including all tests necessary to determine the nature of an illness or injury, in accordance with the provider agreement when applicable.

N.J. Admin. Code § 11:24-5.3

Amended by R.2008 d.60, effective 3/17/2008.
See: 39 N.J.R. 3466(a), 40 N.J.R. 1668(a).
Rewrote (b)5; and added (c).