Chapter 417-F: Coverage for Emergency Services

In this chapter:

I. "Emergency medical condition" means "emergency medical condition" as defined in RSA 420-J:3, XV.

II. "Emergency services" means "emergency services" as defined in RSA 420-J:3, XVI.

III. "Insurer" means any entity providing managed care coverage or accident or health insurance or accident and health insurance policies, contracts, certificates, or other evidence of coverage to enrollees, insureds, or subscribers pursuant to RSA 415, 415-A, 420-A, 420-B, or 420-J.

An insurer retrospective review of a claim for reimbursement for emergency services shall include consideration of presenting symptoms, along with final diagnosis, and shall give due consideration to the definitions of emergency medical condition and emergency services in RSA 420-J:3.

I. A participating provider or other authorized representative of the plan that gives prior authorization shall not rescind or modify the authorization after the health care provider has rendered the authorized emergency services care in good faith and the enrollee's, insured's, or subscriber's coverage was effective on the date of service.

II. When emergency services are a covered benefit under a health plan subject to this chapter, no prior authorization shall be required for emergency services necessary to screen and stabilize an individual.

III. No health benefit plan shall require a prior authorization for medically necessary interfacility transports for services related to the treatment and diagnosis of certain biologically-based mental illnesses.

Following the completion of an involuntary admission certificate for a patient meeting the criteria under RSA 135-C:27 and not rescinded under RSA 135-C:29-a, the insurer shall pay the acute care hospital a per diem day rate required to board and care for the patient, to be contracted between the insurer and acute care hospital, for each day the insured is waiting in an acute care medical hospital located in the state for admission for psychiatric treatment at New Hampshire Hospital, a community-based designated receiving facility, or a voluntary admission. The day rate required to board and care for the patient may be billed for up to 21 consecutive days or discharge, whichever is sooner, and shall be renewed as needed for patient protection. The rate is deemed to cover all costs incurred by a hospital for the boarding and non-medical care of the insured and shall not be billed to the insured. This does not preclude a hospital from billing for other medically necessary services. Any qualified mental health worker employed by or contracted with the hospital, community mental health care center, or affiliate providing mental health services and supports to an insured in an emergency department in the hospital service areas while they are waiting for an inpatient or other psychiatric admission shall be reimbursed for those mental health services including diagnostic services by the insurer at the negotiated rate. Mental health services provided in this setting under this section shall be deemed medically necessary and shall not require prior authorization by an insurer. This section shall apply to the Medicaid managed care organizations subject to contract and rate agreements between the state of New Hampshire and the managed care organizations. The reimbursement for emergency room board and care shall be incorporated into the capitated rate for managed care services.

Whenever mental health services are a covered benefit under a health benefit plan subject to this chapter, community based mental health crisis intervention services that otherwise meet the definition of emergency services as set out in RSA 417-F:1, I shall be treated as emergency services under this chapter without the requirement of being provided in a licensed hospital emergency facility if such services are provided under the program established in RSA 167:3-l, III.