Pennsylvania Act 1996-112 — INSURANCE COMPANIES - HOSPITAL EMERGENCY FACILITY

Act text

INSURANCE COMPANIES - HOSPITAL EMERGENCY FACILITY
                 Act of Jul. 11, 1996, P.L. 655, No. 112              Cl. 40
                                  AN ACT

     Requiring reimbursement by insurers for certain services
        performed by a hospital emergency facility.

        The General Assembly of the Commonwealth of Pennsylvania
     hereby enacts as follows:

     Section 1.  Definitions.
        The following words and phrases when used in this act shall
     have the meanings given to them in this section unless the
     context clearly indicates otherwise:
        "Insurer."  The term means:
            (1)  Any insurance company, association or reciprocal,
        nonprofit hospital plan corporation.
            (2)  A nonprofit professional health service plan.
            (3)  A health maintenance organization organized and
        regulated under the act of December 29, 1972 (P.L.1701,
        No.364), known as the Health Maintenance Organization Act.
            (4)  A risk-assuming preferred provider organization
        organized and regulated under the act of May 17, 1921
        (P.L.682, No.284), known as The Insurance Company Law of
        1921.
            (5)  A preferred provider with a health management
        gatekeeper role for primary care physicians organized and
        regulated as a health services corporation or a preferred
        provider organization subject to the provisions of section
        630 of The Insurance Company Law of 1921.
            (6)  A fraternal benefit society subject to the
        provisions of the act of December 14, 1992 (P.L.835, No.134),
        known as the Fraternal Benefit Societies Code.
        "Medical emergency."  A medical condition with acute symptoms
     of severity or severe pain for which:
            (1)  care is sought as soon as possible after the medical
        condition becomes evident to the patient or the patient's
        parent or guardian; and
            (2)  the absence of immediate medical attention could
        result in:
                (i)  placing health in serious jeopardy;
                (ii)  serious impairment to bodily functions;
                (iii)  serious dysfunction of any body part; or
                (iv)  other serious medical consequences.
     Section 2.  Reimbursement.
        (a)  Requirement.--An insurer shall reimburse an insured or
     provider for medically necessary services that are provided in a
     hospital emergency facility due to a medical emergency.
        (b)  Information.--A hospital emergency facility shall
     provide to an insurer, with any claim for reimbursement of
     services, information on the presenting symptoms of the insured
     as well as the services provided.
        (c)  Factors considered.--An insurer shall consider both the
     presenting symptoms and the services provided in processing a
     claim for reimbursement of emergency services.
     Section 3.  Effective date.
        This act shall take effect in 180 days.