Ariz. Admin. Code § R9-22-217 - Services Included in the Federal Emergency Services Program
A. Definition.
Notwithstanding the definition in
R9-22-201, for the purposes of this Section, an emergency medical or behavioral health
condition for a FES member means a medical condition or a behavioral health
condition, including labor and delivery, manifesting itself by acute symptoms
of sufficient severity, including severe pain, such that the absence of
immediate medical attention could reasonably be expected to result in:
1. Placing the member's health in serious
jeopardy,
2. Serious impairment to
bodily functions,
3. Serious
dysfunction of any bodily organ or part, or
4. Serious physical harm to another
person.
B. Services.
"Emergency services for a FES member" mean those medical or behavioral health
services provided for the treatment of an emergency condition. Emergency
services include outpatient dialysis services for a FES member with End Stage
Renal Disease (ESRD) where a treating physician has certified for the month in
which services are received that in the physician's opinion the absence of
receiving dialysis at least three times per week would reasonably be expected
to result in:
1. Placing the member's health
in serious jeopardy, or
2. Serious
impairment of bodily function, or
3. Serious dysfunction of a bodily organ or
part.
C. Covered
services. Services are considered emergency services if all of the criteria
specified in subsection (A) are satisfied at the time the services are
rendered. The Administration shall determine whether an emergency condition
exists on a case-by-case basis.
D.
Prior authorization. A provider is not required to obtain prior authorization
for emergency services for FES members. Prior authorization for outpatient
dialysis services is met when the treating physician has completed and signed a
monthly certification as described in subsection (B).
E. Services rendered through the Federal
Emergency Services Program are subject to all exclusions and limitation on
services in this Article including but not limited to the limitations on
inpatient hospital services in R9-22-204.
Notes
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