State Law

Missouri Statutes-Title XXIV-Chapter 376. Life, Health and Accident Ins-Health Care Utilization Review

08/09/2023 Missouri Section 376.1367

Emergency services benefit determination, coverage required, when

State Medical Necessity Decisions-Deadlines

When conducting utilization review or making a benefit determination for emergency services:

(1)  A health carrier shall cover emergency services necessary to screen and stabilize an enrollee, as determined by the treating emergency department health care provider, and shall not require prior authorization of such services;

(2)  Coverage of emergency services shall be subject to applicable co-payments, coinsurance and deductibles;

(3)  Before a health carrier denies payment for an emergency medical service based on the absence of an emergency medical condition, it shall review the enrollee’s medical record regarding the emergency medical condition at issue.  If a health carrier requests records for a potential denial where emergency services were rendered, the health care provider shall submit the record of the emergency services to the carrier within forty-five processing days, or the claim shall be subject to section 376.383.  The health carrier’s review of emergency services shall be completed by a board-certified physician licensed under chapter 334 to practice medicine in this state;

(4)  When an enrollee receives an emergency service that requires immediate post evaluation or post stabilization services, a health carrier shall provide an authorization decision within sixty minutes of receiving a request; if the authorization decision is not made within sixty minutes, such services shall be deemed approved;

(5)  When a patient’s health benefit plan does not include or require payment to out-of-network health care providers for emergency services including but not limited to health maintenance organization plans, as defined in section 354.400, or a health benefit plan offered by a health carrier consistent with subdivision (19) of section 376.426, payment for all emergency services as defined in section 376.1350 necessary to screen and stabilize an enrollee shall be paid directly to the health care provider by the health carrier.  Additionally, any services authorized by the health carrier for the enrollee once the enrollee is stabilized shall also be paid by the health carrier directly to the health care provider.