12VAC5-408-280: Urgent care and emergency services

A. The MCHIP licensee shall require that participating providers allow its covered persons, on a 24-hour basis, (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a covered person for prompt medical care in cases where there is a need for urgent care or emergency services.

B. The MCHIP licensee shall provide clear and understandable explanation to covered persons and providers of:

1. What constitutes emergency and urgent care;

2. The process for accessing emergency and urgent care;

3. The responsibility of the covered person for payment for nonemergency services rendered in a hospital emergency facility; and

4. Coverage for out-of-network emergency medical care when a covered person cannot reasonably access network services.

C. The MCHIP licensee shall require its providers to clearly notify covered persons of provisions for urgent care or emergency services when the physician is not available after hours.

D. The MCHIP licensee shall recognize primary care practitioners' authority to facilitate and authorize emergency services for covered persons.

E. Coverage of costs for emergency services shall be consistent with the evidence of coverage and shall not interfere with covered person access to care.

F. Covered persons shall be allowed immediate access to emergency services and access within no more than 24 hours for urgent care. Urgent care access may be provided sooner with appropriate authorization.

G. The MCHIP licensee shall monitor usage of urgent care and emergency service to determine if the services are understood and appropriately used by covered persons and providers.