State Law

2018 Act 103

08/21/2023 Pennsylvania Section 1/Section 2116

Emergency services

OON-Payment Issues

If an enrollee seeks emergency services and the emergency health care provider determines that emergency services are necessary, the emergency health care provider shall initiate necessary intervention to evaluate and, if necessary, stabilize the condition of the enrollee without seeking or receiving authorization from the managed care plan.  The managed care plan shall pay all reasonably necessary costs associated with emergency services provided during the period of emergency, subject to all copayments, coinsurances or deductibles. When processing a reimbursement claim for emergency services, a managed care plan shall consider both the presenting symptoms and the services provided. The emergency health care provider shall notify the enrollee’s managed care plan of the provision of emergency services and the condition of the enrollee. If an enrollee’s condition has stabilized and the enrollee can be transported without suffering detrimental consequences or aggravating the enrollee’s condition, the enrollee may be relocated to another facility to receive continued care and treatment as necessary.

(b) For emergency services rendered by a licensed emergency medical services agency, as defined in 35 Pa.C.S. § 8103 (relating to definitions), that has the ability to transport patients or is providing and billing for emergency services under an agreement with an emergency medical services agency that has that ability, the managed care plan may not deny a claim for payment solely because the enrollee did not require transport or refused to be transported.

(c) For emergency services provided to medical assistance participants, the following provisions shall apply:

(1) The provisions of subsection (b) shall apply to the same services provided to medical assistance participants under Article IV of the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code.

(2) Payment for the services shall be in accordance with the current managed care contracted rates.

(3) Sufficient funds shall be appropriated each fiscal year for payment of the services.

(d) The provisions of subsection (b) shall apply to all group and individual major medical health insurance policies issued by a licensed health insurer.