South Carolina Code 38-71-1530. Screening; initial intervention; role of managed care organization; payments to providers
(B) Appropriate intervention must be initiated by medical personnel to stabilize any emergency medical condition before requesting authorization for the treatment by a managed care organization.
Terms Used In South Carolina Code 38-71-1530
- Coinsurance: means a stipulation or requirement that the insured undertakes to be his own insurer to the extent that he fails to maintain insurance of a given percentage of the value of the property against loss or damage. See South Carolina Code 38-1-20
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
- Emergency medical care: means those health care services provided in a hospital emergency facility to evaluate and treat an emergency medical condition. See South Carolina Code 38-71-1520
- Emergency medical condition: means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
(a) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part. See South Carolina Code 38-71-1520 - Fraud: Intentional deception resulting in injury to another.
- Insurer: includes a corporation, fraternal organization, burial association, other association, partnership, society, order, individual, or aggregation of individuals engaging or proposing or attempting to engage as principals in any kind of insurance or surety business, including the exchanging of reciprocal or interinsurance contracts between individuals, partnerships, and corporations. See South Carolina Code 38-1-20
- Managed care organization: means a licensed insurance company, a hospital or medical services plan contract, a health maintenance organization, or any other entity which is subject to regulation by the department and which operates a managed care plan. See South Carolina Code 38-71-1520
- Policy: means a contract of insurance. See South Carolina Code 38-1-20
(C) A managed care organization shall inform its insureds, enrollees, patients, and affiliated providers about all policies related to emergency medical care access, coverage, payment, and grievance procedures. It is the ultimate responsibility of the managed care organization to inform any contracted third party administrator, independent contractor, or primary care provider about the emergency medical care provisions contained in this subsection.
(D) A managed care organization which includes emergency medical care services as part of its policy or contract shall provide coverage and shall subsequently pay providers for emergency medical care services provided to an insured, enrollee, or patient who presents an emergency medical condition. This subsection must not be construed to require coverage for illnesses, diseases, equipment, supplies, or procedures or treatments which are not otherwise covered under the terms of the insured’s policy or contract.
(E) A managed care organization may not retrospectively deny or reduce payments to providers for emergency medical care of an insured, enrollee, or patient even if it is determined that the emergency medical condition initially presented is later identified through screening not to be an actual emergency, except in these cases:
(1) material misrepresentation, fraud, omission, or clerical error;
(2) a payment reduction due to applicable co-payments, coinsurance, or deductibles which may be the responsibility of the insured;
(3) cases in which the insured does not meet the emergency medical condition definition, unless the insured has been referred to the emergency department by the insured’s primary care physician or other agent acting on behalf of the insurer.