1262.8
. (a) A noncontracting hospital shall not bill a patient who
is an enrollee of a health care service plan for poststabilization
care, except for applicable copayments, coinsurance, and deductibles,
unless one of the following conditions are met:
(1) The patient or the patient's spouse or legal guardian refuses
to consent, pursuant to subdivision (f), for the patient to be
transferred to the contracting hospital as requested and arranged for
by the patient's health care service plan.
(2) The hospital is unable to obtain the name and contact
information of the patient's health care service plan as provided in
subdivision (c).
(b) If a patient with an emergency medical condition, as defined
by Section 1317.1, is covered by a health care service plan that
requires prior authorization for poststabilization care, a
noncontracting hospital, except as provided in subdivision (n),
shall, prior to providing poststabilization care, do all of the
following once the emergency medical condition has been stabilized,
as defined by Section 1317.1:
(1) Seek to obtain the name and contact information of the patient'
s health care service plan. The hospital shall document its attempt
to ascertain this information in the patient's medical record, which
shall include requesting the patient's health care service plan
member card or asking the patient, or a family member or other person
accompanying the patient, if he or she can identify the patient's
health care service plan, or any other means known to the hospital
for accurately identifying the patient's health care service plan.
(2) Contact the patient's health care service plan, or the health
plan's contracting medical provider, for authorization to provide
poststabilization care, if identification of the plan was obtained
pursuant to paragraph (1).
(A) The hospital shall make the contact described in this
subparagraph by either following the instructions on the patient's
health care service plan member card or using the contact information
provided by the patient's health care service plan pursuant to
subdivision (j) or (k).
(B) A representative of the hospital shall not be required to make
more than one telephone call to the health care service plan, or its
contracting medical provider, provided that in all cases the health
care service plan, or its contracting medical provider, shall be able
to reach a representative of the hospital upon returning the call,
should the plan, or its contracting medical provider, need to call
back. The representative of the hospital who makes the telephone call
may be, but is not required to be, a physician and surgeon.
(3) Upon request of the patient's health care service plan, or the
health plan's contracting medical provider, provide to the plan, or
its contracting medical provider, the treating physician and surgeon'
s diagnosis and any other relevant information reasonably necessary
for the health care service plan or the plan's contracting medical
provider to make a decision to authorize poststabilization care or to
assume management of the patient's care by prompt transfer.
(c) A noncontracting hospital that is not able to obtain the name
and contact information of the patient's health care service plan
pursuant to subdivision (b) is not subject to the requirements of
this section.
(d) (1) A health care service plan, or its contracting medical
provider, that is contacted by a noncontracting hospital pursuant to
paragraph (2) of subdivision (b), shall, within 30 minutes from the
time the noncontracting hospital makes the initial contact, do either
of the following:
(A) Authorize poststabilization care.
(B) Inform the noncontracting hospital that it will arrange for
the prompt transfer of the enrollee to another hospital.
(2) If the health care service plan, or its contracting medical
provider, does not notify the noncontracting hospital of its decision
pursuant to paragraph (1) within 30 minutes, the poststabilization
care shall be deemed authorized, and the health care service plan, or
its contracting medical provider, shall pay charges for the care, in
accordance with the Knox-Keene Health Care Service Plan Act of 1975
(Chapter 2.2 (commencing with Section 1340) of Division 2) and any
regulation adopted thereunder.
(3) If the health care service plan, or its contracting medical
provider, notified the noncontracting hospital that it would assume
management of the patient's care by prompt transfer, but either the
health care service plan or its contracting medical provider fails to
transfer the patient within a reasonable time, the poststabilization
care shall be deemed authorized, and the health care service plan,
or its contracting medical provider, shall pay charges, in accordance
with the Knox-Keene Health Care Service Plan Act of 1975 (Chapter
2.2 (commencing with Section 1340) of Division 2 of the Health and
Safety Code) and any regulation adopted thereunder, for the care
until the enrollee is transferred.
(4) If the health care service plan, or its contracting medical
provider, provides authorization to the noncontracting hospital for
specified poststabilization care and services, the health care
service plan, or its contracting medical provider, shall be
responsible to pay for that authorized care.
(e) If a health care service plan, or its contracting medical
provider, decides to assume management of the patient's care by
prompt transfer, the health care service plan, or its contracting
medical provider, shall do all of the following:
(1) Arrange and pay the reasonable charges associated with the
transfer of the patient.
(2) Pay for all of the immediately required medically necessary
care rendered to the patient prior to the transfer in order to
maintain the patient's clinical stability.
(3) Be responsible for making all arrangements for the patient's
transfer, including, but not limited to, finding a contracted
facility available for the transfer of the patient.
(f) (1) If the patient, or the patient's spouse or legal guardian
refuses to consent to the patient's transfer under subdivision (e),
the noncontracting hospital shall promptly provide a written notice
to the patient or the patient's spouse or legal guardian indicating
that the patient will be financially responsible for any further
poststabilization care provided by the hospital.
(2) For patients whose primary language is one of the Medi-Cal
threshold languages, the notice shall be delivered to them in their
primary language.
(3) The Department of Managed Health Care shall translate the
notice required by this subdivision in all Medi-Cal threshold
languages and make the translations available to the hospitals
subject to this section.
(4) The written notice provided pursuant to this subdivision shall
include the following statement: