Section R9-22-217. Services Included in the Federal Emergency Ser- vices Program

A.      Definition. Notwithstanding the definition in R9-22-201, for the purposes of this Section, an emergency medical or behav- ioral health condition for a FES member means a medical con- dition 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 imme- diate 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 treat- ment 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 physi- cian’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 certifi- cation as described in subsection (B).

E.       Services rendered through the Federal Emergency Services Program are subject to all exclusions and limitation on ser- vices in this Article including but not limited to the limitations on inpatient hospital services in R9-22-204.

Historical Note

Adopted under an exemption from the provisions of the Administrative Procedure Act, effective July 1, 1993

(Supp. 93-3). Amended under an exemption from the pro- visions of the Administrative Procedure Act, effective October 26, 1993 (Supp. 93-4). Section repealed, new

Section adopted effective September 22, 1997 (Supp. 97-

3). Amended by exempt rulemaking at 7 A.A.R. 5701,

effective December 1, 2001 (Supp. 01-4). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by final rulemaking at

11 A.A.R. 5480, effective December 6, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R.

3351, effective November 10, 2007 (Supp. 07-3).

Amended by final rulemaking at 17 A.A.R. 1658, effec- tive August 2, 2011 (Supp. 11-3). Amended by exempt

rulemaking at 17 A.A.R. 1868, effective October 1, 2011 (Supp. 11-3). Amended by final rulemaking at 19 A.A.R. 2747, effective October 8, 2013 (Supp. 13-3). Amended by final rulemaking at 20 A.A.R. 3098, effective January 4, 2015 (Supp. 14-4).