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22 CCR 53622
22 CCR 53622
§ 53622. Definitions.
(a)
The following definitions shall govern the construction of this article unless the context or subject matter otherwise requires:
(1)
“Day” means a calendar day.
(2)
“Dispute” means a dispute concerning payment for care under emergency circumstances provided to plan members by nonplan providers.
(3)
“Emergency services” or “care under emergency circumstances” means those health care services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which if not immediately diagnosed and treated would lead to disability or death. Such emergency is deemed to continue until:
(A)
In reasonable medical judgment, the patient's condition has stabilized sufficiently so as to permit either:
(1)
Discharge, or
(2)
Referral and transfer of the patient, in accordance with instructions from the patient's plan, to such level of treatment or care as may be appropriate, and
(B)
A reasonable time within which to complete such discharge, or referral and transfer.
(4)
“Party” means the provider, the plan or any person, other than an officer or employee of the Department acting in an official capacity, who has been allowed to appear in the proceeding.
(5)
“Provider” means a nonplan provider who files a claim against a plan for emergency services in accordance with this article.
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