2018 California Code
Health and Safety Code - HSC
DIVISION 2 - LICENSING PROVISIONS
CHAPTER 2.2 - Health Care Service Plans
ARTICLE 5 - Standards
Section 1371.5.

(a)  No health care service plan that provides basic health care services shall require prior authorization or refuse to pay for any ambulance or ambulance transport services, referred to in paragraph (6) of subdivision (b) of Section 1345, provided to an enrollee as a result of a “911” emergency response system request for assistance if either of the following conditions apply:

(1)  The request was made for an emergency medical condition and ambulance transport services were required.

(2)  An enrollee reasonably believed that the medical condition was an emergency medical condition and reasonably believed that the condition required ambulance transport services.

(b)  As used in this section, “emergency medical condition” has the same meaning as in Section 1317.1.

(c)  The determination as to whether an enrollee reasonably believed that the medical condition was an emergency medical condition that required an emergency response shall not be based solely upon a retrospective analysis of the level of care eventually provided to, or a final discharge of, the person who received emergency assistance.

(d)  A health care service plan shall not be required to pay for any ambulance or ambulance transport services if the health care service plan determines that the ambulance or ambulance transport services were never performed, an emergency condition did not exist, or upon findings of fraud, incorrect billings, the provision of services that were not covered under the member’s current benefit plan, or membership that was invalid at the time services were delivered for the pending emergency claim.

(Added by Stats. 1998, Ch. 979, Sec. 3. Effective January 1, 1999.)