N.J. Admin. Code § 10:74-9.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:74-9.1 - Emergency services

(a) The contractor shall, on a 24-hour-a-day, seven-day-a-week basis, make available emergency services, that is, those services within or outside of the contractor's enrollment area, required to be provided to an enrollee as a result of an onset of a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in placing the health of the person or others in serious jeopardy; serious impairment to such person's bodily functions; serious dysfunction of any bodily organ or part of such person, or serious disfigurement of such person. With respect to a pregnant woman who is having contractions, an emergency exists when there is inadequate time to effect a safe transfer to another hospital before delivery or when such a transfer may pose a threat to the health or safety of the woman or unborn child. Emergency services shall also include:

1. Medical examinations at an emergency room for suspected physical/child abuse and/or neglect.

2. Medical examinations at an emergency room in accordance with 10:122D-2.5(b) when a foster home placement of a child occurs after business hours.

3. In regard to post-stabilization of care, the contractor shall comply with 42 CFR 422.113(c) incorporated herein by reference, as amended and supplemented. The contractor shall cover post-stabilization services without requiring authorization and regardless of whether the enrollee obtains the services within or outside the contractor's network, if:

i. The services were pre-approved by the contractor or its providers;

ii. The services were not pre-approved by the contractor because the contractor did not respond to the provider of post-stabilization care services' request for pre-approval within one hour after being requested to approve such care; or

iii. The contractor could not be contacted for pre-approval.

(b) The contractor shall give the enrollee an explanation of where and how 24 hour a day emergency medical care and out-of-area coverage is available, and shall explain to the enrollee the procedure for obtaining treatment for emergency care.

(c) Emergency services, as distinguished at (a) above, are covered services, even if they have not been authorized by the MCO.

(d) The contractor shall be responsible for developing procedures for review and approval by DMAHS and for advising its enrollees of procedures for obtaining emergency services when it is not medically feasible for enrollees to receive emergency services from or through a participating provider or when the time required to reach the participating provider would mean risk of permanent damage to the enrollee's health. The contractor shall bear the cost of providing emergency service through non-participating providers.

(e) Prior authorization shall not be required for emergency services.

(f) The contractor shall pay for all medical screening services rendered to its members by hospitals and emergency room physicians. The amount and method of reimbursement for medical screenings shall be subject to negotiations between the contractor and the hospital and directly with non-hospital-salaried emergency room physicians and shall include reimbursement for urgent care and non-urgent care rates. Non-participating hospitals may be reimbursed for hospital costs at Medicaid/NJ FamilyCare rates or other mutually agreeable rates for medical screening services. Additional fees for additional services may be included at the discretion of the contractor and the hospital.

1. The managed care entity shall be liable for payment for the following emergency services provided to an enrollee:

i. If the medical screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition exists, the managed care entity shall pay for both the services involved in the screening examination and the services required to stabilize the patient.

ii. All emergency services which are medically necessary until the clinical emergency is stabilized. This includes all treatment that is necessary to assure, within reasonable medical probability, that material deterioration of the patient's condition is not likely to result from, or occur during, discharge of the patient or transfer of the patient to another facility. If there is a disagreement between a hospital and the contractor concerning whether the patient is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the member at the treating facility shall prevail and be binding upon the contractor. The contractor may establish arrangements with hospitals whereby the contractor may send one of its own physicians with appropriate ER privileges to assume the attending physician's responsibilities to stabilize, treat, or transfer the patient.

iii. If the medical screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition does not exist, but the enrollee had acute symptoms of sufficient severity at the time of presentation to warrant emergency attention under the prudent layperson standard, the MCE shall pay for all services involved in the medical screening examination.

iv. If the enrollee's PCP or other plan representative instructs the enrollee to seek emergency care in-network or out-of-network, whether or not the patient meets the prudent layperson standard.

2. The managed care entity shall not retroactively deny a claim for an emergency medical screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, was subsequently determined to be non-emergency in nature.

(g) Prior authorization for medical screenings and urgent care shall not be required. This provision shall apply to out-of-network as well as in-network providers. The hospital emergency room physician may determine the necessity to contact the PCP or the contractor for information about a patient who presents with an urgent condition. The PCP shall be called if the patient is to be admitted.

(h) The contractor's agreement with the hospital must require the hospital to notify the contractor of a hospital admission through the emergency room within 24 to 72 hours of the admission.

(i) The contractor's agreement with the hospital must require the hospital to notify the contractor of all of its members who present in the emergency room for non-emergent care who have been medically screened but not admitted as an inpatient within 24 to 72 hours of the rendered service. The contractor and the hospitals will negotiate how this notification shall occur.

(j) The contractor shall not limit what constitutes an emergency medical condition based on lists of diagnoses or symptoms.

(k) Women who arrive at any emergency room in active labor shall be considered as an emergency situation and the contractor shall reimburse providers of care accordingly.

(l) As required by 42 U.S.C. § 1396u-2(b)(2)(D), all non-participating providers of emergency services including, but not limited to, non-contracted hospitals providing emergency services to Medicaid/NJ FamilyCare members enrolled in the managed care program, shall accept, as payment in full, the amounts that the non-contracted providers and/or hospitals would receive from Medicaid/NJ FamilyCare for the emergency services and/or any related hospitalization as if the beneficiary were enrolled in FFS Medicaid.

N.J. Admin. Code § 10:74-9.1

Amended by 51 N.J.R. 1359(a), effective 8/19/2019