Procedures

Follow the steps below to approve EMA:

Step 1 Obtain a signed application from the applicant and determine the appropriate COA under which EMA will be processed. Step 2 Review and obtain a signed Notification of Eligibility – Emergency Medical Assistance Program form from each individual making application for EMA. A copy of the signed notice should be placed in the case record. If the applicant is not present for a face-to-face interview, the EMA Notification form must be mailed to the applicant. It is preferable that the notice be signed and returned but it is not required. Step 3 Determine the AU and BG and complete the budgeting process for the appropriate COA. Step 4 Establish basic eligibility for the AU with the exception of citizenship/immigration status, and enumeration. Step 5 Obtain DMA Form 526 or a written, signed statement from the physician verifying the need for emergency medical services. The signature should be the original signature of the physician, or a medically trained employee of the physician designated to act on his/her behalf. Forms using the physician’s stamped signature are not acceptable. Faxes are acceptable if the form is faxed from the physician’s office and the signature on the faxed form was original. When questionable, contact the physician’s office to verify. The following providers are authorized to sign Form 526: Any qualified licensed professional (i.e., RN, MD, advanced practice RNs, midwife, PA, etc.) DMA Form 526 or physician’s statement should not indicate a period of emergency service exceeding 30 days from condition onset date. No future dates are to appear on DMA Form 526. In order for a Form 526 to be valid, it must have both a begin and an end date for services provided and the dates of service must be prior to the date the form is signed by the physician or qualified licensed professional. Step 6 Approve the case using the appropriate COA if the applicant meets all eligibility criteria. Notify the AU of the eligibility determination. The notice should include the following: approval/disposition date Gateway Client ID number date(s) of eligibility Step 7 A CMD is not required. Applicants will need to complete a new application for subsequent emergency services received.