Arizona Laws 20-2804. Utilization review; medically necessary emergency services
A. A health care services plan engaging in utilization review to determine whether any emergency services rendered by a provider were medically necessary and in accordance with this chapter shall consider the following factors:
Terms Used In Arizona Laws 20-2804
- Emergency services: means health care services that are provided to an enrollee in a licensed hospital emergency facility by a provider after the recent onset of a medical condition that manifests itself by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(a) Serious jeopardy to the patient's health. See Arizona Laws 20-2801
- Enrollee: means an individual, or a dependent of that individual, who is currently enrolled with and covered by a health care services plan. See Arizona Laws 20-2801
- Fraud: Intentional deception resulting in injury to another.
- Health care services plan: means a plan offered by a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation or medical service corporation that contractually agrees to pay or make reimbursement for health care expenses for one or more individuals residing in Arizona but does not apply to benefits provided under limited benefit coverage as defined in section 20-1137. See Arizona Laws 20-2801
- Prior authorization: means authorization by telephone or telefacsimile given in advance of the performance of an emergency service on an enrollee, by a health care services plan after receipt of necessary medical and enrollment information on the enrollee. See Arizona Laws 20-2801
- Provider: means any physician, hospital or other person that is licensed or otherwise authorized to furnish emergency services in this state. See Arizona Laws 20-2801
1. Current emergency medical literature and standards of care.
2. Clinical information reasonably available to the provider at the time of the services.
B. A health care services plan shall not deny a claim for emergency services on the basis that the services were not medically necessary without review by a physician of the plan’s choosing.
C. For the purpose of claims payment and utilization review of emergency services, a health care services plan shall have the right to require as a condition of payment that each treating provider produce all of the following:
1. Copies of all medical records pertaining to the emergency services provided to the enrollee.
2. Copies of records pertaining to any prior authorization and specialty consultation requests made by the provider.
3. A detailed and itemized billing statement.
D. If a health care services plan pays any portion of a provider’s claim for services rendered to an enrollee, the plan shall not be permitted to recover all or part of that payment from the enrollee, except for:
1. The cost of an initial medical screening examination and related charges where the examination determined that emergency services were not medically necessary.
2. Payments made as a result of misrepresentation, fraud or clerical error.
3. Copayment, coinsurance or deductible amounts that are the responsibility of the enrollee.