Section 2116. Emergency Services.--(a) If a covered person or enrollee seeks emergency services and the emergency health care provider determines that emergency services are necessary, the emergency health care provider shall initiate necessary intervention to evaluate and, if necessary, stabilize the condition of the covered person or enrollee without seeking or receiving authorization from the insurer or MA or CHIP managed care plan. The insurer or MA or CHIP managed care plan may not require a health care provider to submit a request for prior authorization for an emergency service. The insurer or MA or CHIP managed care plan shall pay all reasonably necessary costs associated with emergency services provided during the period of emergency, subject to all copayments, coinsurances or deductibles. When processing a reimbursement claim for emergency services, an insurer or MA or CHIP managed care plan shall consider both the presenting symptoms and the services provided.
(a.1) The emergency health care provider shall notify the covered person's insurer or enrollee's MA or CHIP managed care plan of the provision of emergency services and the condition of the covered person or enrollee.
(1) The health care provider shall notify a covered person's insurer of the provision of emergency services and the condition of the covered person within two business days following the period of emergency.
(2) The health care provider shall notify the enrollee's MA or CHIP managed care plan of the provision of emergency services and the condition of the enrollee within ten days following the presentation for emergency services.
(a.2) If a covered person's or enrollee's condition has stabilized and the covered person or enrollee can be transported without suffering detrimental consequences or aggravating the covered person's or enrollee's condition, the covered person or enrollee may be relocated to another facility to receive continued care and treatment as necessary.
(b) For emergency services rendered by a licensed emergency medical services agency, as defined in 35 Pa.C.S. § 8103 (relating to definitions), that has the ability to transport patients or is providing and billing for emergency services under an agreement with an emergency medical services agency that has that ability, the insurer or MA or CHIP managed care plan may not deny a claim for payment solely because the enrollee did not require transport or refused to be transported. The requirements of subsection (a.1) do not apply to a licensed emergency medical services agency under this paragraph.
(c) For emergency services provided to MA or CHIP managed care plan enrollees, the following provisions shall apply:
(1) The provisions of subsection (b) shall apply to the same services provided to medical assistance participants under Article IV of the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code.
(2) Payment for the services shall be in accordance with the current MA or CHIP managed care contracted rates.
(3) Sufficient funds shall be appropriated each fiscal year for payment of the services.
(d) ((d) deleted by amendment).
(2116 amended Nov. 3, 2022, P.L.2068, No.146)
Compiler's Note: See section 3 of Act 103 of 2018 in the appendix to this act for special provisions relating to applicability.