2005 Minnesota Statutes

     62Q.55 Emergency services. 

    (a) Enrollees have the right to available and accessible 
 emergency services, 24 hours a day and seven days a week.  The 
 health plan company shall inform its enrollees how to obtain 
 emergency care and, if prior authorization for emergency 
 services is required, shall make available a toll-free number, 
 which is answered 24 hours a day, to answer questions about 
 emergency services and to receive reports and provide 
 authorizations, where appropriate, for treatment of emergency 
 medical conditions.  Emergency services shall be covered whether 
 provided by participating or nonparticipating providers and 
 whether provided within or outside the health plan company's 
 service area.  In reviewing a denial for coverage of emergency 
 services, the health plan company shall take the following 
 factors into consideration: 

    (1) a reasonable layperson's belief that the circumstances 
 required immediate medical care that could not wait until the 
 next working day or next available clinic appointment; 

    (2) the time of day and day of the week the care was 
 provided; 

    (3) the presenting symptoms, including, but not limited to, 
 severe pain, to ensure that the decision to reimburse the 
 emergency care is not made solely on the basis of the actual 
 diagnosis; 

    (4) the enrollee's efforts to follow the health plan 
 company's established procedures for obtaining emergency care; 
 and 

    (5) any circumstances that precluded use of the health plan 
 company's established procedures for obtaining emergency care. 

    (b) The health plan company may require enrollees to notify 
 the health plan company of nonreferred emergency care as soon as 
 possible, but not later than 48 hours, after the emergency care 
 is initially provided.  However, emergency care which would have 
 been covered under the contract had notice been provided within 
 the set time frame must be covered. 

    (c) Notwithstanding paragraphs (a) and (b), a health plan 
 company, health insurer, or health coverage plan that is in 
 compliance with the rules regarding accessibility of services 
 adopted under section 62D.20 is in compliance with this section. 

    HIST: 1997 c 237 s 11