CA HMO/PPO Patient Rights to Emergency and Poststabilization Services and Care
You have a right to receive emergency services and care, including, but not limited to, medical screening, examination and evaluation to determine if a medical emergency exists; and the care, treatment and surgery necessary to relieve or eliminate the emergency medical condition until you are stabilized, WITHOUT the need of prior authorization (Health and Safety § 1317.1), (Health and Safety § 1371.4 (a-b.))
You have a right to receive emergency services and care at any health facility licensed in the State of California that maintains and operates an emergency department to provide emergency services to the public when the health facility has *appropriate facilities and qualified personnel available to provide the services or care. *IF YOUR HOSPITAL DOES NOT HAVE APPROPRIATE FACILITIES AND QUALIFIED PERSONNEL (LACK OF BEDS, PEDIATRICIANS, ETC.), YOU HAVE A RIGHT TO HAVE AN ER TO ER TRANSFER, WITHOUT THE NEED OF PRIOR AUTHORIZATION (H&S Code §1317(a).)
You have a right to have your medical bills paid in the event your medical screening, examination and evaluation determines no emergency medical condition or active labor exists (H&S Code §1317.1 (a); 1371.4 (b), 1371.5 (c); Also see Prudent Layperson Standard.)
You have a right for your stabilization to be determined by the opinion of your treating provider who examined you instead of an off-site physician who has not seen you (H&S Code § 1317.1(j).)
You have a right to have your health plan make a decision to either authorize medically necessary poststabilization services and care or arrange transfer to another contracted facility within 30 minutes of the initial phone call/notification of your hospital notifying them of the admission and *requesting authorization. *YOU DO NOT NEED TO OBTAIN YOUR OWN AUTHORIZATION IN THE EVENT OF AN EMERGENCY ADMISSION (H&S Code § 1262.8 (d)(1-2); H&S Code § 1371.4(j); 28 CCR § 1300.71.4 (b).)
You have a right to have your medical bills paid if your health plan decides to assume management of your care within 30 minutes, including, (1) The arrangement and payment of the reasonable charges associated with your transfer and (2) Payment for all of the immediately required medically necessary care rendered to you prior to the transfer in order to maintain your clinical stability (H&S Code § 1262.8 (e)(1-2.)
You have a right to have your health plan responsible for making ALL arrangements for your transfer, including, but not limited to, finding a contracted facility available for your transfer (H&S Code § 1262.8 (e)(3).)
You have a right to be provided a written notice indicating that you will be financially responsible for any further poststabilization care provided by the hospital if you refuse to consent to transfer (H&S Code § 1262.8 (f)(1.)
You have a right to have your medical bills paid if your health plan failed to disapprove payment for your care (in writing) *prior to or during the continuation of care. Services are deemed authorized and payment for this care may not be denied. *IN BOTH CASES, THE DISRUPTION OF CARE (TAKING INTO ACCOUNT THE TIME NECESSARY TO EFFECT YOUR TRANSFER OR DISCHARGE) CANNOT HAVE AN ADVERSE IMPACT UPON THE EFFICACY OF YOUR CARE AND MEDICAL CONDITION (28 CCR § 1300.71.4 (b)(2).)
You have a right to be placed under observation deemed medically necessary by your physician for a period longer than 24 hours until your physician makes a decision to admit or discharge you, WITHOUT the need for *prior authorization. *OBSERVATION LEVEL OF CARE IS CONSIDERED AN ER OUTPATIENT UNDER FEDERAL GUIDELINES.
You have a right to file a grievance with the health plan if a request for medical services or treatment is denied.
You have a right to request an Independent Medical Review from the Department of Managed Health Care if you disagree with plan’s decision.
You have a right to file a grievance with the Department of Managed Health Care if your care is delayed or denied improperly, OR if you are *balanced billed (H&S Code § 1368 and 1379.) *UNDER EXISTING CALIFORNIA LAW, A NONCONTRACTING HOSPITAL MAY NOT BILL A PATIENT FOR THE DIFFERENCE BETWEEN THE MEDICAL SERVICE PROVIDER’S ACTUAL CHARGES FOR EMERGENCY SERVICES AND THE AMOUNT THE PROVIDER WAS REIMBURSED FROM THE PATIENT’S INSURANCE PLAN. A NONCONTRACTING HOSPITAL MAY BALANCE BILL IF A PATIENT OR THE PATIENT’S SPOUSE OR LEGAL GUARDIAN REFUSES TO CONSENT FOR A TRANSFER ARRANGED BY THE PLAN OR THE HOSPITAL IS UNABLE TO OBTAIN THE NAME AND CONTACT INFORMATION OF THE PATIENT’S PLAN (H & S Code § 1262.8 (a)(c)(f.)
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