Office of Managed Care Operations

EMERGENCY ROOM REGULATIONS

New Jersey Regulations/Federal Regulations

All HMOs

	No prior authorization is required to perform a screening exam.
	Emergency Treatment should not be delayed.
	EMTALA: Every patient is entitled to a medically screening examination to determine if an emergency exists. This is regardless of their ability to pay or their insurance status. The screening must be performed without any delay to obtain information about the patient’s ability to pay or to inquire about insurance status. The screening exam should be the same exam that the hospital would perform on any individual coming to the ER.
	Trauma: The hospital ER should stabilize the patient. Patients can only be transferred to another facility (if the HMO requests, or the hospital cannot provide the needed service) if patient no longer requires critical care and can safely be transferred.
	All determinations to deny or limit an admission, service, procedure, or extension of stay shall be rendered by a physician.
	An HMO shall not retroactively deny reimbursement for a covered service provided to a member by a provider who relied upon the authorization of the HMO prior to providing the service.

Medicaid HMOs

In addition to the above, the following rules apply:

	No prior authorization for urgent care (includes active labor).
	The ER physician may determine the necessity to contact the PCP or the HMO for information about a patient who presents with an urgent condition.
	The PCP must be called if the patient is to be admitted.
	The hospital must notify the HMO of a hospital admission through the ER within 24–72 hours of the admission (depending on the HMO rules – see section X1).

Medicare HMOs

	No prior authorization required for emergency services.
	HMOs cannot retroactively deny a claim because a condition, which appeared to be an emergency, turns out to be non-emergency in nature.

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Last Reviewed:November 2005
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