Section 154.14. Emergency services

(a) Managed care plans are prohibited from requiring that enrollees or health care providers obtain prior authorization for emergency services as defined by section 2102 of the act (40 P. S. § 991.2102).

(b) Plans are required to pay all reasonably necessary costs for enrollees meeting the prudent layperson definition of emergency services provided during the period of the emergency, including evaluation, testing, and if necessary, the stabilization of the condition of the enrollee.

(c) Sudden and unexpected medical events involving a chronic condition which meet the prudent layperson requirements of the act shall be considered emergency services subject to the act and this chapter.

(d) Plans are required to consider the presenting symptoms as documented by the claim file, and the services provided, when processing claims for emergency services.

(e) The emergency health care provider shall notify the enrollee’s managed care plan of the provision of emergency services and the condition of the enrollee.

(1) If the enrollee is admitted to a hospital or other health care facility, the emergency health care provider shall notify the enrollee’s managed care plan of the emergency services delivered within 48 hours or on the next business day, whichever is later. An exception to this requirement will be made where the medical condition of the patient precludes the provider from accurately determining the identity of the enrollee’s managed care plans within 48 hours of admission.

(2) If the enrollee is not admitted to a hospital or other health care facility, the claim for reimbursement for emergency services provided shall serve as notice to the enrollee’s managed care plan of the emergency services provided by the emergency health care provider.

(f) Managed care plans shall supply each enrollee, and upon written request, each prospective enrollee or health care provider, with the information concerning emergency services in § 154.16(h) (relating to information for enrollees).