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46 Effective Date: July 1, 2009

Approval Date: specifying how to access emergency medical care within 24 hours per day, 7 days per week. In addition, emergency care services for medical emergencies must be provided in non-participating facilities when a member: • Has a medical emergency meeting the contract definition and is not able to use a participating hospital (42 CFR 434.30), or • Presents at a non-participating hospital emergency department and the member’s condition is determined to be non-emergency. In such instances, the MCO must cover facility and professional services for medical screening examinations as defined in the contract.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State’s contract with MCOs requires the MCO to provide all medically necessary specialty care for enrollees. If an enrollee needs specialty care from a specialist who is not available within the MCO’s provider network, the MCO must provide the necessary services with a qualified specialist outside of the MCO’s provider network.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) Washington follows Washington Administrative Code 388-501-0165 related to the prior authorization of services.