PURPOSE: This rule sets forth the requirements of a health maintenance organization when prior authorization for emergency medical services is required. This rule is promulgated pursuant to section 354.485, RSMo and implements sections 354.410.1(2) and 354.470.1(3), RSMo.

1. (1) A health maintenance organization
2. (HMO) that requires prior authorization before making payment for the treatment of medical emergency conditions, as defined by the HMO, shall provide enrollees with a tollfree telephone number answered twenty-four
3. (24) hours per day, seven (7) days a week. At least one (1) person with medical training who is authorized to determine whether an emergency condition exists shall be available twenty-four (24) hours per day, seven (7) days a week to make these determinations.
4. (2) An HMO shall not base its denial of payment for emergency medical services solely on the enrollee’s failure to receive authorization prior to receiving the emergency medical service. The enrollee must notify the HMO of receipt of medical services for emergency conditions within twenty-four (24) hours or as soon after that as is reasonably possible. Nothing shall require the HMO to authorize payment for any services provided during that twenty-four (24)-hour period, regardless of medical necessity, if those services do not otherwise constitute benefits under the certificate of coverage approved by the department.
5. (3) If the participating provider is responsible for seeking prior authorization from the HMO before receiving payment for the treatment of emergency medical conditions and the enrollee is eligible at the time when covered services are provided, then the enrollee will not be held financially responsible for payment for covered services if the prior authorization for emergency medical services has not been sought and received, other than for what s/he would otherwise be responsible, such as copayments and deductibles.
6. (4) All disputes between an enrollee and an HMO arising under the provisions of this regulation shall be resolved by means of the HMO’s grievance procedure.
7. (5) Discipline. The director of the Department of Insurance may institute disciplinary action for violation of this rule in accordance with the provisions of section 354.500, RSMo and any other applicable law.

AUTHORITY: sections 354.410, 354.470 and 354.485, RSMo 1986.* Original rule filed April 14, 1992, effective Feb. 26, 1993.

*Original authority: 354.410, RSMo 1983; 354.470, RSMo 1983; and 354.485, RSMo 1983.