1. (a) Except as provided in subsection (b), “emergency services” means those services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to disability or death.

2. (b) For purposes of providing treatment of an emergency medical condition to otherwise eligible aliens pursuant to Welfare and Institutions Code Section 14007.5(d), “emergency medical condition” means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

   1. (1) Placing the patient's health in serious jeopardy.
   2. (2) Serious impairment to bodily functions.
   3. (3) Serious dysfunction of any bodily organ or part.

3. (c) Emergency services are exempt from prior authorization, but must be justified according to the following criteria:

   1. (1) Any service classified as an emergency, which would have been subject to prior authorization had it not been so classified, must be supported by a physician's, podiatrist's, dentist's, or pharmacist's statement which describes the nature of the emergency, including relevant clinical information about the patient's condition, and states why the emergency services rendered were considered to be immediately necessary. A mere statement that an emergency existed is not sufficient. It must be comprehensive enough to support a finding that an emergency existed. Such statement shall be signed by a physician, podiatrist, dentist, or pharmacist who had direct knowledge of the emergency described in this statement.

      1. (A) The provision for pharmacist certification of emergency services shall pertain only to the dispensing of drugs.
   2. (2) The Department may impose postservice prepayment audit as set forth in Section 51159(b), to review the medical necessity of emergency services provided to beneficiaries. The Department may require providers to follow the procedures for obtaining authorization on a retroactive basis as the process for imposing postservice prepayment audits. Requests for retroactive authorization of emergency services must adequately document the medical necessity of the services and must justify why the services needed to be rendered on an emergency basis.
4. (d) Program limitations set forth in Sections 51304 and 51310 are not altered by this section.

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; Section 57(c), Chapter 328, Statutes of 1982; and Section 147, Chapter 722, Statutes of 1992. Reference: Sections 14007.5, 14059, 14103.6, 14132, 14133 and 14133.1, Welfare and Institutions Code; and Title 42, United States Code, Section 1396b(v)(3).

History

1. Amendment of subsections (a) and (b) and new subsection (c) filed 9-27-72; designated effective 11-1-72 (Register 72, No. 40). For prior history, see Register 72, No. 5.

2. Amendment of subsection (b) filed 1-30-73; effective thirtieth day thereafter (Register 73, No. 5).

3. Amendment of subsection (b) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.

4. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-3-83 (Register 83, No. 6).

5. Change without regulatory effect of Note (Register 86, No. 49).

6. Amendment of subsection (a), new subsections (b)-(b)(3), and subsection relettering filed 4-12-93; operative 4-12-93. Submitted to OAL for printing only pursuant to SB 485, section 147 (Register 93, No. 16).

7. Amendment of subsection (c)(1) and new subsection (c)(1)(A) filed 8-7-95 as an emergency; operative 8-7-95 (Register 95, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-5-95 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as to 8-7-95 order transmitted to OAL 11-30-95 and filed 1-11-96 (Register 96, No. 2).