Emergency Medical Assistance
Note: Refer to Kidney Transplant Services and End Stage Renal Disease (ESRD) under Provider Basics in the Minnesota Health Care Programs (MHCP) Provider Manual for information about emergency medical assistance coverage specific to those services.
Overview
Emergency Medical Assistance (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 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 Emergency Medical Assistance - Care Plan Certification Request (DHS-3642).
Members must meet all the following criteria:
EMA also covers the following services when approved through an EMA CPC:
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 within 24 to 48 hours it could reasonably result in the following:
Care Plan Certification (CPC)
MHCP expects to process each CPC request within 15 business days of receiving the request and will send a notification letter to both the requesting provider and member. Each notification letter will include the following information:
Requesting Care Plan Certification
To request care plan certification, refer to the following instructions:
If you are requesting the CPC for dates of service before the date you submit the CPC request, specify that retroactive start date in the requested start date box.
Submit the completed EMA CPC request and supporting documentation to Acentra, the medical reviewer, through the Acentra online portal or fax to 844-472-3779.
The medical reviewer determines which conditions meet the definition of an emergency medical condition. They cannot approve diagnoses that are not listed on the CPC request. The medical reviewer may approve a CPC for no more than 12 consecutive months. Care for diagnoses that are short-term, will have shorter approval dates.
Services requiring further authorization
Upon approval of a qualifying condition through a CPC, some services may still require further authorization to be covered. Review the service-specific section of the MHCP Provider Manual for additional information and instruction about authorization requirements. After the CPC process has been completed, further authorization timelines begin. It may be necessary to send additional information to the appropriate review agent.
The following services will always require further authorization in addition to CPC for coverage under EMA:
Requesting Renewal of a Care Plan Certification
Providers must request recertification 30 days before a CPC certification ends and include all necessary documentation to support the medical necessity for continuing the CPC. Timely renewal of the CPC will minimize disruption of the member’s medical care.
Emergency dental services
A member’s dental clinic requests CPC and authorization for an emergency dental procedure and related treatment.
Home care agencies
Along with the CPC, 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 required documentation item. 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)/community first services and supports (CFSS) agencies
If the member has an approved EMA medical condition that requires PCA/CFSS services, the provider contacts the county to request an assessment for CFSS services. Refer to Community First Services and Supports (CFSS) in the MHCP Provider Manual for more information.
Pharmacy outpatient prescription drugs
A member’s provider or dentist completes the CPC request, including listing drugs the member will need in the “drugs” section of the CPC request that correlates with the appropriate diagnosis. The physician or dentist should list drugs by name and strength, route and drug form.
Do not send the initial CPC form to the pharmacy reviewer before a CPC is approved by the medical reviewer. Requests sent directly to the pharmacy reviewer will not be reviewed.
If the medical reviewer determines a drug is necessary for treatment of an emergency medical condition, they will send the CPC that includes those drugs necessary for treatment to the pharmacy reviewer.
The pharmacy reviewer will receive the requests for drugs from the medical reviewer and will add to the system for drug coverage. The MHCP member and prescriber identified on the CPC request will each receive notice of the status of requests for outpatient prescription drugs in a CPC approval letter from the medical reviewer.
If a drug also requires a clinical prior authorization, the provider will submit the Prescription Drug Prior Authorization Form (available under Resources - Forms and Documents on the Minnesota Medical Assistance Portal) to the pharmacy reviewer before the drug will be authorized for the member. A drug being included in the member’s CPC does not mean the pharmacy reviewer has automatically approved the clinical prior authorization.
Provider administered drug authorization
For provider-administered injection authorization (J Code drugs), the provider must complete the care plan certification (CPC) including adding the drugs in the “drugs” section of the CPC that correlates with the appropriate diagnosis.
Do not send the initial CPC form to the pharmacy reviewer before the CPC is approved by the medical reviewer. Requests sent directly to the pharmacy reviewer will not be reviewed.
If a drug requires a clinical prior authorization, the pharmacy reviewer will evaluate the submitted Prescription Drug Prior Authorization Form (available under Resources - Forms and Documents on the Minnesota Medical Assistance Portal) against the clinical criteria. A drug being included in the member’s CPC does not mean the pharmacy reviewer has automatically approved the clinical prior authorization.
Refer to the Drug Authorizations section of the MHCP Provider Manual for additional details
Change note: Please note process changes in the Provider administered drug authorization section.
Psychiatric Residential Treatment Facility
The provider completes, signs and submits a CPC request with clinical information to the EMA medical reviewer.
The provider also completes and submits the Authorization Form (DHS-4695) (PDF) to the Behavioral Health Medical Reviewer. Refer to Psychiatric Residential Treatment Facility under the Mental Health Services section of the MHCP Provider Manual for additional information.
Expedited Review for Members Awaiting Hospital Discharge
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 medical reviewer by phone before faxing the CPC request.
Review EMA Sample Scenarios under Provider Basics in the MHCP Provider Manual for sample medical condition situations to help determine if CPC is appropriate.
Changes to an Existing CPC
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 instructions for requesting a CPC. All currently approved diagnoses will be reviewed at the time of renewal so there will be one review time for all diagnoses. For example, if you submit a new diagnosis two months before the original CPC is due for review, all diagnoses will have the same date on the renewal.
Requesting authorization for services or drugs not included in the initial CPC request
If a member requires a service that usually requires further authorization, or requires home care, PCA/CFSS 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 reviewer.
Covered Services
EMA will cover only services necessary to treat a diagnosis approved through the CPC process as an emergency medical condition. Services that currently require further authorization under MHCP will continue to require an 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.
Noncovered Services
Services that are not covered include, but are not limited to, the following:
Pharmacy and prescription-related items are not covered for the following conditions (this list does not include all conditions not covered):
Types of drugs that are not covered under EMA include, but are not limited to, the following:
Billing
When you submit claims for items or services approved through CPC, include the following:
If billing a diagnosis code is not expected to be repeated and was excluded 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 conditions.
MHCP continues to follow all other billing policy guidelines when processing these claims.
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