Limitations on emergency room services

1. For purposes of this section, "screening" means the initial evaluation of an individual, intended to determine suitability for a particular medical treatment modality. 2. The provider of emergency services shall assure that a recipient is referred to the appropriate health delivery setting, including the recipient's enrolled in-state provider, when emergency room services are not judged to be appropriate. 3. Payment for emergency room services. a. Claims for payment, and documentation in support of those claims, must be submitted on forms prescribed by the department. The claim must contain sufficient documentation to indicate that a medical emergency required emergency room diagnostic services and treatment. b. Except as provided in subsection 4, providers must be paid for any medically necessary services. c. Except as provided in subsection 4, providers must be paid for screening or examination services rendered. d. Providers must be paid for services rendered to recipients who reside outside of the provider's regular service area and who do not normally utilize the provider's services. 4. If the emergency room service claim does not demonstrate the existence of a medical emergency, payment must be denied (except for screening services) unless the services are shown to be medically necessary by a redetermination. The provider, upon receipt of notice of denial, may, in writing, make a redetermination request to the department. A redetermination must include a statement refuting the stated basis for the payment denial and affirmatively demonstrating a medical emergency.