California Health and Safety Code1262.8, includes various provisions regarding emergency and post-stabilization care. Post-stabilization care is defined as medically necessary care provided after an emergency medical condition has been stabilized as defined by subdivision (j) of Section 1317.1.
Health Plan of San Joaquin (HPSJ) is required to provide specific health plan contact information and 24-hour access to request prior authorizations for post-stabilization care when a HPSJ member receives emergency medical care from a non-contracted hospital.
If treating an HPSJ patient with an emergency medical condition, as defined by 1317.1, a prior authorization is required from HPSJ for post-stabilization care. The stabilizing hospital should conduct the following:
- The hospital shall contact HPSJ UM at the following phone number 209-461-2205 to obtain timely authorization for post-stabilization care
HPSJ requests the treating physician and surgeon’s diagnosis and any other relevant information reasonably necessary to make a decision in authorizing post-stabilization care or to assume management of the patient’s care by prompt transfer. HPSJ shall not require a hospital representative or a physician and/or surgeon to make more than one telephone call to the number provided in advance by HPSJ. The representative of the hospital may be but is not required to be a physician and/or surgeon.
When HPSJ is contacted by a non-stabilizing hospital and within 30 minutes from the time of the initial contact, HPSJ shall conduct either of the following:
- Authorize post-stabilization care.
- In case of a potential transfer, Inform the hospital that it will arrange for the prompt transfer for the enrollee to another hospital.
Admitting facility should fax admission facesheet and clinical documentation to the Inpatient Department fax, 209-762-4702. Assigned Concurrent Review Nurse will collaborate with the facility in discharge planning.
A health care service plan that is contacted by a hospital pursuant to Section 1262.8 shall reimburse the hospital for post-stabilization care rendered to the enrollee if any of the following occur:
- The health care service plan authorizes the hospital to provide post-stabilization care.
- The health care service plan does not respond to the hospital’s initial contact or does not make a decision regarding whether to authorize post-stabilization care or to promptly transfer the enrollee within the timeframe noted above. The request shall be deemed authorized.
- There is an unreasonable delay in the transfer of the enrollee, and the noncontracting physician and surgeon determines that the enrollee requires post-stabilization care.
An enrollee who is billed by a hospital in violation of Section 1262.8 may report receipt of the bill to the health care service plan and the department. The department shall forward that report to the State Department of Public Health.