DCS Comprehensive Health Plan

Emergency Services

Statement/Purpose

This policy outlines the amount, duration and scope of emergency medical services covered by the Department of Child Safety Comprehensive Health Plan (DCS CHP).

Definitions

Emergency Condition: a medical or behavioral condition, including labor and delivery, which manifests 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:

• Placing the health of the individual (or with respect to a pregnant woman, her unborn child), including mental health, in serious jeopardy.

• Serious impairment of bodily functions.

• Serious dysfunction of any bodily organ or part.

• Serious physical harm to another person

Post Stabilization Care Services: Medically necessary services, related to an emergency medical condition that are provided after the member’s condition is sufficiently stabilized in order to maintain, improve or resolve the member’s condition so that the member can be safely transferred to another location or discharged as specified in 42 CFR 438.114(a).

Prior Authorization (PA): Approval from a health plan that may be required before you get a service. This is not a promise that the health plan will cover the cost of the service.

Prior Authorization (PA) Request Submission Process: The process by which authorization requests are submitted with clinical documentation supporting the medical necessity for the services requested.

Policy

Emergency medical services are provided to DCS CHP members for the treatment of an emergency medical condition. An emergency medical condition is a medical condition (including labor and delivery) which manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possess an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or with respect to a pregnant woman, her unborn child) in serious jeopardy;

• Serious impairment to bodily functions;

• Serious dysfunction of any bodily organ or part; or

• Serious physical harm to another person.

DCS CHP covers emergency medical services for children and youth when there is a demonstrated emergent condition as defined above. A provider or facility is not required to obtain prior authorization for covered emergency medical services. However, a provider shall comply with the notification and post-stabilization requirements in Arizona Administrative Code (A.A.C.) R9- 22-210.

Emergency medical services are covered when the provider furnishing the service is not registered with DCS CHP Mercy Care’s Provider Network.

DCS CHP does not deny payment or limit emergency service in the following situations or reasons:

• Provider furnishing the services is not registered with the Mercy Care DCS CHP network;

• Based on a list of diagnoses or symptoms including behavioral health;

• Provider, hospital, or fiscal agent did not request prior authorization or sends in notification within 10 days;

• DCS CHP staff instructs the member to obtain emergency medical services

• Post stabilization care services (provided under the definition of an emergency medical condition) in order to maintain the stabilized condition or to improve or resolve the patient’s condition when:

  • Post stabilization care services were not approved by DCS CHP,

  • Situations in which DCS CHP and the treating physician cannot reach an agreement concerning the member’s care and the physician is not available for consultation; and

• Attending emergency physician has determined that the member is not sufficiently stabilized for transfer or discharge

Transportation to the emergency department of an acute care hospital is covered when the transport is emergent including inter-facility transfer to the emergency department.

Inter facility transfers between inpatient facilities following emergency hospitalization and to facilitate post stabilization care services are covered.

DCS CHP may deny a payment for emergency services if:

• The claim was not a clean claim;

• The claim was not submitted timely; or

• The provider failed to provide timely notification of the emergency service provided and DCS CHP has no alternate indication that the service was provided. Notification is required no later than the 11th day after the emergency service.

Procedure

Care Coordination

DCS CHP requests that facilities providing emergency services notify DCS CHP’s contracted MCO to initiate care coordination activities as needed. Notification is provided via Fax Notification Form or by phone within 10 calendar days from the time a member presents for emergency services. If the member remains in the emergency department greater than 24 hours after being medically cleared the emergency room is to provide the health plan with a list of members to initiate care coordination for appropriate services.

Care coordination opportunities are identified based upon the information provided on notification of emergency services. Care coordination opportunities include, but are not limited to:

• Pregnancy;

• Behavioral health conditions;

• Frequent utilization;

• Prolonged ED stay due to awaiting appropriate level of care (BH or PH)

• Special health care needs;

• Members with a CRS designation (qualifying condition);

• Disease management; and

• Controlled substance use/misuse evaluation.

Reporting/Monitoring

Emergency Department (ED) utilization is one of the components that may be reviewed to enroll a member in a higher level of care coordination. ED utilization reports are generated and evaluated to inform care coordination and determine over utilization of emergency services.

On a monthly basis, DCS CHP provides AHCCCS with an Over 24 hours ED Bed Hold Report. This report summarizes the activities and average hold times for members remaining in the emergency room over 24 hours post medical clearance.

On a bi-annual basis, DCS CHP provides AHCCCS with an ED Diversion Summary which reports the number of members who utilized the ED four (4) or more times in a six (6) month period, along with the interventions conducted. This is not a member specific report. It is expected that each member may have more than one intervention.