W. Va. Code R. § 114-50-4

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-50-4 - Requirements for Emergency Medical Services

4.1. If a health maintenance organization enters into a contract with an emergency medical service provider:

a. The health maintenance organization shall file with the commissioner a copy of the executed contract and all exhibits, attachments, addenda, schedules or other documents relevant to the contract forty-five (45) days after the calendar quarter end next following the execution date of an emergency medical service provider contract;

b. The health maintenance organization shall report any new or deleted emergency medical service providers on the provider list submitted to the commissioner with its quarterly financial statement; and

c. A health maintenance organization is responsible for compliance by the participating provider with all applicable standards required by W. Va. Code '33-25A-1 et seq. as to any services performed on behalf of the health maintenance organization.

4.2. A health maintenance organization may not prohibit enrollees' use of "911" or another method of contacting an emergency medical service provider in an emergency situation.

4.3. A health maintenance organization must explain clearly and concisely in its evidence of coverage:

a. That neither an enrollee nor a provider is required to obtain preauthorization or precertification for acute emergency medical services;

b. That the health maintenance organization may apply to covered emergency medical services the same deductibles, coinsurance and other limitations that apply to other covered health care services;

c. What is an emergency situation and how the health maintenance organization will determine whether health care services qualify as covered emergency medical services, giving specific examples of situations in which an enrollee should seek emergency medical services by calling the health maintenance organization, A911" or a comparable community dispatcher;

d. That the enrollee will be liable for provider charges for noncovered emergency medical services;

e. Under what conditions non-acute emergency medical services, by an emergency medical service provider or otherwise, will be a covered health care service; and

f. That, if an enrollee receives covered acute emergency medical services from a nonparticipating provider, the health maintenance organization will pay the provider's normal charges for the covered emergency medical services rendered, exclusive of any applicable deductibles or copayments to be paid by the enrollee.

W. Va. Code R. § 114-50-4