(a) A utilization review entity shall not require prior authorization for prehospital transportation or for provision of an emergency healthcare service.
(b) (1) A utilization review entity shall allow a subscriber and the subscriber's healthcare provider a minimum of twenty-four (24) hours following an emergency admission or provision of an emergency healthcare service for the subscriber or healthcare provider to notify the utilization review entity of the admission or provision of an emergency healthcare service.
(2) If the admission or emergency healthcare service occurs on a holiday or weekend, a utilization review entity shall not require notification until the next business day after the admission or provision of the emergency healthcare service.
(c) (1) A utilization review entity shall cover emergency healthcare services necessary to evaluate and assess the health condition of a subscriber or to stabilize a subscriber.
(2) If a healthcare provider certifies in writing to a utilization review entity within seventy-two (72) hours of a subscriber's admission that the subscriber's condition required an emergency healthcare service, that certification will create a presumption that the emergency healthcare service was medically necessary, and such presumption may be rebutted only if the utilization review entity can establish, with clear and convincing evidence, that the emergency healthcare service was not medically necessary.
(d) (1) The determination by a utilization review entity of medical necessity or medical appropriateness of an emergency healthcare service shall not be based on whether the emergency healthcare service was provided by a healthcare provider that is a member of the health benefit plan's provider network.
(2) Restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is not a member of the health benefit plan's provider network shall not be greater than restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is a member of the health benefit plan's provider network.
(e) (1) If a subscriber receives an emergency healthcare service that requires an immediate post-evaluation or post-stabilization healthcare service, a utilization review entity shall make an authorization within sixty (60) minutes of receiving a request.
(2) If the authorization is not made within sixty (60) minutes, the emergency healthcare service shall be approved.
Section: Previous 23-99-1102 23-99-1103 23-99-1104 23-99-1105 23-99-1106 23-99-1107 23-99-1108 23-99-1109 23-99-1110 23-99-1111 23-99-1112 23-99-1113 23-99-1114 NextLast modified: November 15, 2016