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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyPHC California ED Communication Coverage | OpenPay…
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    CurrentPHC CaliforniaPolicy UM 37.3

    PHC-CA Communication Protocols with Emergency Departments

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    Governs Emergency Department communications, emergency-service access, post-stabilization authorization, referrals, failure reporting, and follow-up care for PHC California personnel, providers, hospitals, and Emergency Department staff.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA Communication Protocols with Emergency Departments
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2024
    Last ReviewOct 15, 2025
    Next Review DateN/A
    Key ActionRespond to post-stabilization authorization requests within 30 minutes by authorizing care or arranging a prompt transfer.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    24/7Emergency and post-stabilization coordination access
    30 minPost-stabilization response time
    1 callMaximum hospital calls for authorization
    NonePrior authorization for emergency services

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    30 days
    Provider grievance resolution

    Emergency and Post-Stabilization Coverage

    Post-stabilization authorization

    Covered when all of the following requirements are met:

    ALL of the following

    • ALL of the following

      • The enrollee has received emergency services, care is stabilized, and the treating provider believes the enrollee may not be safely discharged.
      • The hospital contacts PHC using the designated 24-hour telephone number; the hospital is not required to make multiple calls or use another method of contact.

    • PHC must take one of the following actions within 30 minutes of receiving the request:

      • Authorize medically necessary post-stabilization care.Within 30 minutes
      • Inform the hospital that PHC will arrange a prompt transfer of the enrollee to another hospital.Within 30 minutes

    Emergency-service access

    Emergency services are accessible without prior authorization:

    ALL of the following

    • Emergency services are sought at any time and in any Emergency Department, whether inside or outside the service area.
    • Prior authorization is not required.

    Operational Timeframes and Contact Requirements

    Post-Stabilization Response Time
    Response time30 minutes from receipt of the hospital's authorization request
    Required responseAuthorize post-stabilization care or inform the hospital that PHC will arrange a prompt transfer
    Failure to respondNecessary post-stabilization care delivered by the hospital is deemed authorized
    Hospital Contact Requirements
    Maximum contact attemptsNo more than one telephone call
    Required contact methodThe hospital must use the designated 24-hour contact number
    Prohibited requirement

    Required Communication and Coordination Actions

    Prior Authorization

    Single 24-Hour Authorization Contact

    Maintain a single, uniform point of contact for hospitals seeking post-stabilization authorization, available 24 hours a day. Hospitals must not be required to make multiple calls or use any method other than the Health Plan’s designated telephone number; delegation of phone coverage does not change these requirements.

    • Provide 24-hour access for post-stabilization authorization requests.
    • Use one designated telephone number as the hospital point of contact.
    • Do not require more than one telephone call or contact through another method.
    Prior Authorization

    Respond Within 30 Minutes

    When a hospital contacts the designated 24-hour number, the Health Plan or its delegate must respond within 30 minutes by authorizing post-stabilization care or informing the hospital that the Health Plan will arrange a prompt transfer. If the Health Plan does not respond within that period, medically necessary post-stabilization care provided by the hospital is deemed authorized.

    • Approve or deny the facility’s request within 30 minutes of receipt.

    Key Terms

    Post-Stabilization Care Services
    Relationship to emergency careServices related to an emergency medical condition
    When providedAfter an enrollee is stabilized in an Emergency Department setting
    PurposeTo maintain or improve the stabilized condition
    After Hours
    General meaningHours outside of normal business hours
    Weekday schedule5:30 p.m. through 8:30 a.m. PST
    Non-weekday coverageAll day on weekends and holidays
    Policy Summary
    PayerPHC California
    PolicyPHC-CA Communication Protocols with Emergency Departments
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2024
    Last ReviewOct 15, 2025
    Next Review DateN/A
    Key ActionRespond to post-stabilization authorization requests within 30 minutes by authorizing care or arranging a prompt transfer.
    SourceLink
    On This Page
    Emergency and Post-Stabilization CoverageOperational Timeframes and Contact RequirementsRequired Communication and Coordination ActionsKey Terms
    The hospital may not be required to make multiple calls or use another method of contact
    After-Hours Period
    Weekday hours5:30 p.m. through 8:30 a.m. PST
    Weekend coverageAll day on weekends
    Holiday coverageAll day on holidays
    Provider Grievance Resolution
    Responsible departmentProvider Relations Department
    Resolution deadlineWithin 30 days after receipt of the grievance
    Covered submissionsGrievances submitted by Emergency Departments
  1. Authorize care or arrange a prompt transfer to another hospital.
  2. Treat necessary post-stabilization care as authorized when the required response is not provided on time.

    3. Unsupported block type: info

    Unsupported block type: documentation

    Prior Authorization

    Emergency Services Do Not Require Prior Authorization

    Do not require prior authorization for emergency services. This applies at any time and in any Emergency Department, whether the ED is inside or outside the Health Plan’s service area.

    • Applies to emergency services provided at any time.
    • Applies to participating and non-participating Emergency Departments.
    • Applies both inside and outside the service area.
    • Explain this rule in the Enrollee Handbook/Evidence of Coverage.

    Unsupported block type: documentation

    Unsupported block type: info

    Unsupported block type: documentation