20-2804. Utilization review; medically necessary emergency services

A. A health care services plan engaging in utilization review to determine whether any emergency services rendered by a provider were medically necessary and in accordance with this chapter shall consider the following factors:

1. Current emergency medical literature and standards of care.

2. Clinical information reasonably available to the provider at the time of the services.

B. A health care services plan shall not deny a claim for emergency services on the basis that the services were not medically necessary without review by a physician of the plan's choosing.

C. For the purpose of claims payment and utilization review of emergency services, a health care services plan shall have the right to require as a condition of payment that each treating provider produce all of the following:

1. Copies of all medical records pertaining to the emergency services provided to the enrollee.

2. Copies of records pertaining to any prior authorization and specialty consultation requests made by the provider.

3. A detailed and itemized billing statement.

D. If a health care services plan pays any portion of a provider's claim for services rendered to an enrollee, the plan shall not be permitted to recover all or part of that payment from the enrollee, except for:

1. The cost of an initial medical screening examination and related charges where the examination determined that emergency services were not medically necessary.

2. Payments made as a result of misrepresentation, fraud or clerical error.

3. Copayment, coinsurance or deductible amounts that are the responsibility of the enrollee.