Emergency Room Usage

The medical home provides the foundation for accessing care in the appropriate health care setting. Education of CommunityCARE enrollees is critical in redirecting primary care services rendered in the emergency room. CommunityCARE enrollees need to have a clear understanding of an emergency medical condition, appropriate use of the emergency room, and that Medicaid will only pay for emergencies meeting the prudent layperson definition

Enrollees are encouraged, when possible and appropriate, to contact their PCP before seeking emergency room services. Extensive efforts shall be made by the PCP to educate enrollees on how to access care in the appropriate setting. In addition, each enrollee must be taught the prudent layperson definition of an emergency medical condition in a way that the enrollee understands the information.

Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

• Serious impairment to bodily functions, or

• Serious dysfunction of any bodily organ or part.

Emergency Services: Inpatient and outpatient services needed to evaluate or stabilize an emergency medical condition (as defined above) and furnished by a provider qualified to deliver such services under Medicaid.

If at any time a CommunityCARE enrollee presents to a hospital emergency room or on hospital property for examination and treatment, the enrollee will be provided with a medical screening exam in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) to rule out an emergency medical condition. If the medical screening exam leads to a clinical determination that the enrollee does not have an emergency medical condition, the treating physician will refer the enrollee back to his/her primary care physician (PCP) for treatment. If the exam reveals the existence of an emergency medical condition, the physician will provide such further examination and treatment necessary to stabilize the medical condition.

The three highest levels of emergency room visits do not require a referral/authorization from the CommunityCARE PCP. However, the two lowest levels of emergency room visits do require post-referral/authorization from the PCP.

Post-referral/authorization requests for emergency room services may be either hard copy written requests or electronic requests via the e-RA process at the lamedicaid.com website. (The electronic process is only available for hospitals and PCPs.)

The request for post-authorization, along with pertinent information needed to make an informed decision, should be forwarded to the PCP the next business day for review. The PCP shall respond in writing or via e-RA -- either approving, denying, or requesting additional information -- within 10 working days of receipt of the request.

Approval or denial of post-authorization requests for emergency room services shall be based upon whether or not the presenting symptoms met the prudent lay person standard as outlined above.