Policy:

BlueCross complies with all State and Federal provisions related to the determination of claims for members seeking Emergency Services for an Emergency Medical Condition.

Reference Documents:

• Public Health Service Act (PHS Act) Section 2719A
• Affordable Care Act Implementation FAQs - Part I
• Affordable Care Act Implementation FAQs - Part 31
• SC Access to Emergency Medical Care Act Article 15 (38-71-1520 and 1530)

Definitions:

"Emergency Service" means: "an appropriate medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to determine whether an Emergency Medical Condition exists"; and (2) "such further medical examination and such treatment as may be required to stabilize the medical condition."

"Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonable expect the absence of immediate medical attention to result in:

• Placing the health of the individual, or with respect to a pregnant woman, the health of a woman or her unborn child, in serious jeopardy;
• serious impairment to bodily functions; or
• serious dysfunction of any bodily organ or part.

Responsibilities:

Coverage for Emergency Services must be provided in the following manner:

(i) Without the need for any prior authorization determination, even if the Emergency Services are provided on an out-of-network basis;

(ii) Without regard to whether the health care provider furnishing the Emergency Services is a participating network provider with respect to the services; and

(iii) If the Emergency Services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to Emergency Services received from in-network providers.

Procedure:

Marketing- Documents the benefit in the Group Information Library for fully insured and self-funded groups.  For self-funded groups, Marketing must receive documentation in writing from the group for any deviation from the State and/or Federal requirements.

Benefit Files- Loads the appropriate pay schedule based on the information in the Group Information Library.

Books and Contracts- Creates the group contract and book documents by the benefits loaded in the Group Information Library.

Operations- Ensures the Emergency Services claims are processed to comply with Federal Regulations according to the benefits loaded in the Group Information Library.

System Specifications:

BlueCross with provide coverage for Emergency Services based on any of the following: (i) an emergency room place of service, (ii) an emergency CPT code or (iii) an emergency services revenue code as defined below:

• HIPAA Place of Service
  • 23 (Outpatient ER Department)
• Procedure Codes
  • 99281 - 99285. Emergency department visit for the evaluation and management of a patient. (Each code is based on level of complexity.)
  • 99288. Physician direction of emergency medical services emergency care or advanced life support.
• Revenue Codes
  • 0450- General Classification
  • 0451- EMTALA Emergency Medical Screening Services
  • 0452- ER Beyond EMTALA Screening
  • 0456- Urgent Care
  • 0459- Other Emergency Room
  • 0981- Professional Fees - Emergency Room

Record Retention:

All records related to administration of a qualified health plan will be retained for no less than ten (10) years from the process date.  See HCR C05, Policy and Procedure for Document Retention and Management Pursuant to Qualified Health Plans and 45 C.F.R. § 156.705.

Attachments: 

N/A 

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