California Code of Regulations
Title 28 - Managed Health Care
Division 1 - The Department of Managed Health Care
Chapter 2 - Health Care Service Plans
Article 8 - Self-Policing Procedures
Section 1300.71.4 - Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services
Current through Register 2024 Notice Reg. No. 12, March 22, 2024
The following rules set forth emergency medical condition and post-stabilization responsibilities for medically necessary health care services after stabilization of an emergency medical condition and until an enrollee can be discharged or transferred. These rules do not apply to a specialized health care service plan contract that does not provide for medically necessary health care services following stabilization of an emergency condition.
(a) Prior to stabilization of an enrollee's emergency medical condition, or during periods of destabilization (after stabilization of an enrollee's emergency medical condition) when an enrollee requires immediate medically necessary health care services, a health care service plan shall pay for all medically necessary health care services rendered to an enrollee.
(b) In the case when an enrollee is stabilized but the health care provider believes that the enrollee requires additional medically necessary health care services and may not be discharged safely, the following applies:
(c) In the case where a plan denies the request for authorization of post-stabilization medical care and elects to transfer an enrollee to another health care provider, the following applies:
(d) All requests for authorizations, and all responses to such requests for authorizations, of post-stabilization medically necessary health care services shall be fully documented. All provision of medically necessary health care services shall be fully documented. Documentation shall include, but not be limited to, the date and time of the request, the name of the health care provider making the request, and the name of the plan representative responding to the request.
1. New
section filed 5-9-95 as an emergency; operative 5-9-95 (Register 95, No. 19). A
Certificate of Compliance must be transmitted to OAL by 9-6-95 or emergency
language will be repealed by operation of law on the following
day.
2. New section refiled 9-5-95 as an emergency; operative 9-6-95
(Register 95, No. 36). A Certificate of Compliance must be transmitted to OAL
by 1-4-96 or emergency language will be repealed by operation of law on the
following day.
3. New section refiled 12-19-95 as an emergency;
operative 1-4-96 (Register 95, No. 51). A Certificate of Compliance must be
transmitted to OAL by 4-17-96 or emergency language will be repealed by
operation of law on the following day.
4. Certificate of Compliance,
including amendment of section and NOTE, transmitted to OAL 3-7-96 and filed
4-11-96 (Register 96, No. 15).
5. Editorial correction of first
paragraph and subsections (b)(2), (c) and (c)(1) (Register 96, No.
23).
6. Editorial correction of first paragraph (Register 99, No.
26).
7. Amendment filed 6-24-99 as an emergency; operative 6-24-99
(Register 99, No. 26). A Certificate of Compliance must be transmitted to OAL
by 10-22-99 or emergency language will be repealed by operation of law on the
following day.
8. Certificate of Compliance as to 6-24-99 order
transmitted to OAL 9-30-99 and filed 11-8-99 (Register 99, No.
46).
Note: Authority cited: Sections 1344 and 1371.4(g) and (h), Health and Safety Code. Reference: Sections 1317.1 and 1371.4, Health and Safety Code.