33-20E-4. Payment for emergency medical services.

An insurer that provides any benefits to covered persons with respect to emergency medical services shall pay for such emergency medical services regardless of whether the healthcare provider or facility furnishing emergency medical services is a participating provider or facility with respect to emergency medical services, in accordance with this chapter:#

1. (1)

   Without need for any prior authorization determination and without any retrospective payment denial for medically necessary services; and#

2. (2)

   Regardless of whether the healthcare provider or facility furnishing emergency medical services is a participating provider or facility with respect to emergency medical services.#

In the event a covered person receives the provision of emergency medical services from a nonparticipating emergency medical provider, the nonparticipating provider shall collect or bill no more than such person’s deductible, coinsurance, copayment, or other cost-sharing amount as determined by such person’s policy directly and such insurer shall directly pay such provider the greater of:#

1. (1)

   The verifiable contracted amount paid by all eligible insurers subject to the provisions of this chapter for the provision of the same or similar services as determined by the department;#

2. (2)

   The most recent verifiable amount agreed to by the insurer and the nonparticipating emergency medical provider for the provision of the same services during such time as such provider was in-network with such insurer; or#

3. (3)

   Such higher amount as the insurer may deem appropriate given the complexity and circumstances of the services provided.#

4. Any amount that the insurer pays the nonparticipating provider under this subsection shall not be required to include any amount of coinsurance, copayment, or deductible owed by the covered person or already paid by such person.

A healthcare plan shall not deny benefits for emergency medical services previously rendered based upon a covered person’s failure to provide subsequent notification in accordance with plan provisions, where the covered person’s medical condition prevented timely notification.#

For purposes of the covered person’s financial responsibilities, the healthcare plan shall treat the emergency medical services received by the covered person from a nonparticipating provider or nonparticipating facility pursuant to this Code section as if such services were provided by a participating provider or participating facility, and shall include applying the covered person’s cost-sharing for such services toward the covered person’s deductible and maximum out-of-pocket limit applicable to services obtained from a participating provider or a participating facility under the healthcare plan.#

In the event a covered person receives emergency medical services from a nonparticipating facility, the nonparticipating facility shall bill the covered person no more than such covered person’s deductible, coinsurance, copayment, or other cost-sharing amount as determined by such person’s policy directly.#

All insurer payments made to providers pursuant to this Code section shall be in accord with Code Section 33-24-59.14. Such payments shall accompany notification to the provider from the insurer disclosing whether the healthcare plan is subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C. Sec. 1001, et seq.#