Section 1371.5 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1371.5
. (a) No health care service plan that provides basic health
care services shall require prior authorization or refuse to pay for
any ambulance or ambulance transport services, referred to in
paragraph (6) of subdivision (b) of Section 1345, provided to an
enrollee as a result of a "911" emergency response system request for
assistance if either of the following conditions apply:
(1) The request was made for an emergency medical condition and
ambulance transport services were required.
(2) An enrollee reasonably believed that the medical condition was
an emergency medical condition and reasonably believed that the
condition required ambulance transport services.
(b) As used in this section, "emergency medical condition" has the
same meaning as in Section 1317.1.
(c) The determination as to whether an enrollee reasonably
believed that the medical condition was an emergency medical
condition that required an emergency response shall not be based
solely upon a retrospective analysis of the level of care eventually
provided to, or a final discharge of, the person who received
emergency assistance.
(d) A health care service plan shall not be required to pay for
any ambulance or ambulance transport services if the health care
service plan determines that the ambulance or ambulance transport
services were never performed, an emergency condition did not exist,
or upon findings of fraud, incorrect billings, the provision of
services that were not covered under the member's current benefit
plan, or membership that was invalid at the time services were
delivered for the pending emergency claim.