WAC 182-538-0100 Managed care emergency services.

1. A managed care enrollee may obtain emergency services, for emergency medical conditions from any qualified provider. ("Emergency services" and "emergency medical condition" are defined in WAC 388-538-050.)

   1. The managed care organization (MCO) covers emergency services for MCO enrollees.

   2. The department covers emergency services for primary care case management (PCCM) enrollees.

2. Emergency services for emergency medical conditions do not require prior authorization by the MCO, primary care provider (PCP), PCCM provider, or the department.

3. MCOs must cover all emergency services provided to an enrollee by a provider who is qualified to furnish medicaid services, without regard to whether the provider is a participating or nonparticipating provider.

4. An enrollee who requests emergency services is entitled to receive an exam to determine if the enrollee has an emergency medical condition.  What constitutes an emergency medical condition may not be limited on the basis of diagnosis or symptoms.

5. The MCO must cover emergency services provided to an enrollee when:

   1. The enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of an emergency medical condition; and

   2. The plan provider or other MCO representative instructs the enrollee to seek emergency services.

6. In any disagreement between a hospital and the MCO about whether the enrollee is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the enrollee at the treating facility prevails.

7. Under 42 CFR 438.114, the enrollee's MCO must cover and pay for:

   1. Emergency services provided to enrollees by an emergency room provider, hospital or fiscal agent outside the managed care system; and

   2. Any screening and treatment the enrollee requires subsequent to the provision of the emergency services.