MAO Responsibilities for Coverage of Emergency Services

20.3 – MAO Responsibilities for Coverage of Emergency Services (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) The MAO must inform enrollees of their right to call 911 and: • No materials furnished to enrollees, including wallet card instructions, may contain instructions to seek prior authorization for emergency or urgently needed services; and • No materials furnished to providers, including contracts, may contain instructions to providers to seek prior authorization before the enrollee has been stabilized. The MAO is financially responsible for emergency services and urgently needed services: • Regardless of whether services are obtained within or outside the plan’s authorized service area and/or network (if applicable); • Regardless of whether there is prior authorization for the services; • If the emergency situation is in accordance with a prudent layperson’s definition of “emergency medical condition,” regardless of the final medical diagnosis; and • Whenever a plan provider - a provider with whom the MAO has a written contract to furnish plan covered services to its enrollees - or other plan representative instructs an enrollee to seek emergency services within or outside the plan. The MAO is not responsible for the care provided for an unrelated non-emergency problem during treatment for an emergency situation. For example, if the attending physician is treating a fracture, the plan is not responsible for any costs connected with a biopsy of skin lesions performed while treating the facture.