Coverage for urgent and emergency services out-of-plan
CA | MS"EE. Emergency Services
Provide for care under emergency circumstances in compliance with Title 22, CCR, Section 56216. Educate and instruct members in appropriate use of emergency facilities and services including available options. The Contractor will be responsible for payment of emergency services to the extent that those services are covered under the capitation rate and for authorization of those services not covered by the capitation rate. Emergency services supplied by out-of-state providers will not be covered under the capitation rate or paid by the Contractor...FF. Non-plan Emergency Services Reimbursement
1. Pay for emergency services, as defined in Section V of Article II, received by a member from non-plan providers, when services are covered under the capitation rate. Authorize emergency services, when the services are not covered under the capitation rate. Payments to non-plan providers will be for the treatment of the emergency medical condition including medically necessary services rendered to the member until the time the Contractor can be notified a authorize further service. Emergency services will not be subject to prior authorization by the Contractor. Payment by the Contractor for properly documented claims for emergency services rendered by a non-plan provider will be made within sixty (60) days of receipt by the Contractor, and will not exceed the lower of the following rates applicable at the time the services were rendered by the provider:a. The usual charges made to the general public by the non-plan provider.
b. The maximum fee-for-service rates for similar services under the fee-for-service Medi-Cal program.
c. The contract rate received by the non-plan provider, for similar services, under the Medi-Cal program.2. Pay for those emergency room services required to determine whether treatment of the member's condition qualifies as an emergency service, when those services are covered under the capitation rate. Authorize those services not covered under the capitation rate." California Contract, pages 34-35.
"The Medicaid HealthMACS Primary Care Provider agrees to: ...
6. Provide coverage for emergency medical services without regard to prior authorization or the emergency care provider's contractual relationship with the PCP. Comply with the Medicare guidelines for post-stabilization care.." Mississippi Manual, page A-1.