TMPPM 2009 > Provider Information > Managed Care > PCCM

7.7.21.5 Emergency Outpatient Services

If the client presents at a hospital emergency outpatient facility, the physician should provide the medically necessary medical screening examination and stabilization services immediately, and the client should be referred back to the primary care provider for follow-up care. Reimbursement for emergency outpatient services requires that the medical record document the medically necessary services.

The hospital should contact the client's primary care provider within 24 hours or the next business day to advise that emergency treatment has been provided. In addition, if a procedure requiring authorization was performed while in the emergency department, the hospital must contact the PCCM Outpatient Prior Authorization Department within seven calendar days to obtain the authorization. If the condition results in an inpatient admission, the hospital must notify the PCCM Inpatient Prior Authorization Department prior to claim submission. Reimbursement in cases of emergency treatment will be based on the actual services rendered. The hospital will be reimbursed at its current Medicaid reimbursement rate.

Refer to: "PCCM Inpatient Authorization Process" .

"Outpatient Prior Authorization Process" .