33-21A-4. Reimbursement for emergency health care services.

In particular, but without limitation, a care management organization shall not:#

1. (1)

   Deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or#

2. (2)

   Make payment for emergency health care services contingent on the recipient or provider of emergency health care services providing any notification, either before or after receiving emergency health care services.#

In processing claims for emergency health care services, a care management organization shall consider, at the time that a claim is submitted, at least the following criteria:#

1. (1)

   The age of the patient;#

2. (2)

   The time and day of the week the patient presented for services;#

3. (3)

   The severity and nature of the presenting symptoms;#

4. (4)

   The patient’s initial and final diagnosis; and#

5. (5)

   Any other criteria prescribed by the Department of Community Health, including criteria specific to patients under 18 years of age. A care management organization shall configure or program its automated claims processing system to consider at least the conditions and criteria described in this subsection for claims presented for emergency health care services. The Department of Community Health may develop and publish in print or electronically a list of additional standards to be used by care management organizations to maximize the identification and accurate payment of claims for emergency health care services.#

If a provider that has not entered into a contract with a care management organization provides emergency health care services or post-stabilization services to that care management organization’s member, the care management organization shall reimburse the noncontracted provider for such emergency health care services and post-stabilization services at a rate equal to the rate paid by the Department of Community Health for Medicaid claims that it reimburses directly.#