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| | SB4039 | - 2 - | LRB102 24231 BMS 33460 b |
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1 | | evaluation and treatment
were
rendered to an enrollee who |
2 | | sought emergency services and whose circumstance
did not |
3 | | meet the definition of emergency medical condition;
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4 | | (3) upon determination that the patient receiving such |
5 | | services was not an
enrollee of the health care plan; or
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6 | | (4) upon material misrepresentation by the enrollee or |
7 | | health care
provider; "material" means a fact or situation |
8 | | that is not merely technical in
nature and results or |
9 | | could result in a substantial change in the situation.
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10 | | (d) When an enrollee presents to a hospital seeking |
11 | | emergency services,
the determination as to whether the need |
12 | | for those
services exists shall be made for purposes of |
13 | | treatment by a
physician licensed to practice medicine in all |
14 | | its branches or, to the extent
permitted by applicable law, by |
15 | | other appropriately licensed
personnel under the supervision |
16 | | of
or in collaboration with a physician licensed to practice |
17 | | medicine in all its
branches.
The physician or other
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18 | | appropriate personnel shall indicate in the patient's chart |
19 | | the results of the
emergency medical screening examination.
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20 | | (e) The appropriate use of the 911 emergency telephone |
21 | | system or its local
equivalent shall not be discouraged or |
22 | | penalized by the health care plan when
an emergency medical |
23 | | condition exists.
This provision shall not imply that the use |
24 | | of 911 or its local equivalent is a
factor in determining the |
25 | | existence of an emergency medical condition.
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26 | | (f) The medical director's or his or her designee's
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| | SB4039 | - 3 - | LRB102 24231 BMS 33460 b |
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1 | | determination of whether the enrollee meets the standard of an |
2 | | emergency
medical condition shall be based solely upon the |
3 | | presenting symptoms documented
in the medical record at the |
4 | | time care was
sought.
Only a clinical peer may make an adverse |
5 | | determination.
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6 | | (g) Nothing in this Section shall prohibit the imposition |
7 | | of deductibles,
copayments, and co-insurance.
Nothing in this |
8 | | Section alters the prohibition on billing enrollees contained
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9 | | in the Health Maintenance Organization Act.
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10 | | (Source: P.A. 91-617, eff. 1-1-00.)
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