Note: See the EMA Coverage of Kidney Transplant Services and End Stage Renal Disease (ESRD) subsections for information specific to those services.
EMA (major program code EH) covers the care and treatment of emergency medical conditions provided in an emergency department (ED) or in an inpatient hospital when the admission is the result of an ED admission. Emergency medical conditions include labor and delivery.
Consistent with federal law, EMA covers some care and treatment provided in other settings when the MHCP member’s medical condition(s) is reasonably expected to result in quickly placing his or her health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or function without the care or treatment. EMA will cover these services only if they are part of an approved Care Plan Certification (CPC) Request (DHS-3642) (PDF). Members must meet all the following criteria:
EMA also covers the following services:
For EMA, an emergency medical condition is a medical condition (including emergency labor and delivery) with acute symptoms (including pain) so severe that without immediate medical care or treatment could reasonably result in:
Minnesota Health Care Program (MHCP) expects to process each care plan certification request within 20 business days of receipt and will send a notification letter to both the requesting provider and the member. Each notification letter will include the following information:
To request care plan certification follow these instructions:
The medical review agent determines which conditions meet the definition of an emergency medical condition. They cannot approve diagnoses not listed on the care plan certification request. The medical review agent may approve a care plan certification for no more than 12 consecutive months.
Services requiring authorization
Upon approval of a qualifying condition through care plan certification, some services may still require authorization to be covered. Review the service-specific section of the MHCP Provider Manual for additional information and instruction about authorization requirements. The medical review agent will consider authorization requests for services that routinely require authorization, including outpatient prescription drugs, only after the care plan certification process has been completed and the agent approves a diagnosis that qualifies as an emergency medical condition.
The following services will always require authorization in addition to care plan certification for coverage under EMA:
The review agent will consider requests for authorization of specific services, including prescription drugs, only after the approval of a CPC if the provider completes the “All Other Services” section of the CPC request form with sufficient information to create an authorization.
Providers must request recertification 45 days before a CPC certification ends and include all necessary documentation to support the medical necessity for continuing the care services. Timely renewal of the CPC will minimize disruption of the patient’s medical care.
Emergency dental services
The dental clinic requests CPC and authorization for the emergency dental procedure and related treatment.
Home care agencies
Along with the instructions for requesting care plan certification, also submit an authorization request for nursing and home health aide visits, using the MN–ITS Authorization Request (278) transaction. Include the service authorization (SA) number on each appropriate documentation item listed. Documentation must include a signed physician’s order. The requesting home care agency and the member will each receive notice of the status of the authorization request.
Personal care assistance (PCA) agencies
If the member has an approved EMA medical condition that requires PCA services, the provider contacts the county to request an assessment for PCA services. Refer to the PCA Services section of the manual for additional information.
Pharmacy outpatient prescription drugs
The physician or dentist completes the care plan certification request following the instructions, including listing drugs the member may need in the “All Other Services” section of the CPC request. The physician or dentist must list drugs by name and NDC code, and include the NPI and fax number of the dispensing pharmacy.
The provider also completes the outpatient Drug Prior Authorization Form (DHS-4424) (PDF) for each prescription drug. Fax this form to the medical review agent with the CPC requestor approval letter. Do not send the form to the pharmacy review agent. Requests sent directly to the pharmacy review agent will be returned without review.
If the medical review agent determines a medication is necessary for treatment of an emergency medical condition, they will send the medication or list of medications to the pharmacy review agent to review.
The pharmacy review agent will review requests for outpatient prescription drugs requested to treat a qualifying emergency medical condition and will approve or deny the medication(s) based on standard criteria for coverage under MHCP. The pharmacy and prescriber identified on the care plan certification request and the member will each receive notice of the status of authorization requests for outpatient prescription drugs.
Pharmacy drug authorization
For J Code drug authorizations, the provider must complete the MHCP Authorization Form (DHS-4695) (PDF) for each requested drug. The provider will fax this form and the EMA CPC approval letter to the pharmacy review agent for review. Refer to the Drug Authorization section for additional details.
Psychiatric Residential Treatment Facility
The provider completes, signs and submits a care plan certification request with clinical information to the EMA medical review agent.
The provider also completes and submits the Authorization Form (DHS-4695) (PDF) to the Behavioral Health Medical Review agent. Refer to the Psychiatric Residential Treatment Facility section of the manual for additional information.
To expedite review for hospitalized patients whose discharge plan is contingent on the approval of a CPC, check the field on the EMA CPC request form that indicates the patient is currently hospitalized and awaiting discharge pending approval of the EMA CPC. The hospital may also alert the review agent by phone before faxing the CPC request. The cover sheet on the faxed CPC request should clearly state, “Request for expedited review for hospitalized patient.”
Review the EMA Scenarios page for sample medical condition situations to help determine if care plan certification is appropriate.
Requesting certification of new or additional diagnoses
If a member has a new diagnosis, or a diagnosis that was not included in the initial CPC request, complete a new request following all of the instructions for requesting a care plan certification.
Requesting authorization for services or drugs not included in the initial CPC Request
If a member requires a service that usually requires authorization, or requires home care, PCA or drugs not included in the original CPC request, complete the appropriate service-specific authorization request form. Fax the request form with a copy of the CPC approval letter to the medical review agent.
EMA will cover only services necessary to treat a diagnosis approved through the care plan certification process as an emergency medical condition. Services that currently require an authorization under MHCP will continue to require an authorization. In addition, all dental services and outpatient prescription drugs require authorization.
EMA will cover nonemergency medical transportation only for services covered under EMA.
The MHCP eligibility verification system responses (MN–ITS direct data entry, batch, real-time and voice) do not show a change in the EMA program. Eligibility responses show when a member is eligible for EH.
EMA does not cover the following services:
When you submit claims for items or services approved through care plan certification, include the following:
If billing a diagnosis code that is not expected to be repeated and was not included on the CPC (for example, encounter for removal of vascular catheter), you may include an AUC Cover Sheet with a claims attachment explaining how the diagnosis code is related to the approved condition(s).
MHCP continues to follow all other billing policy guidelines when processing these claims.Report/Rate this page