ModifiedUnitedHealthcarePolicy BIP057.O

Emergency and Urgent Services

Governs coverage, regulatory requirements, and provider obligations for emergency and urgent medical services (including EMTALA and California-specific emergency care rules) for UnitedHealthcare members in North Carolina where specified; this window contains federal and California statutes referenced.

Policy Summary

PayerUnitedHealthcare

PolicyEmergency and Urgent Services

Policy CodePolicy BIP057.O

Change TypeRevisions to California statutory language and updated reference links

Effective DateFeb 1, 2026

Next Review Date

Key ActionDo not require prior authorization for emergency services; for post-stabilization care in California, respond to authorization requests within 30 minutes or care is deemed authorized.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to the California Health and Safety Code (HSC) Section 1317.1.

Replaced reference to 'unborn child' with 'fetus' in State Market Plan Enhancements.

Updated reference links to Title 42 CFR Section 489.24 and House of Representatives 3590, Section 2719A.

EMTALAfederal emergency treatment requirement referenced

HSC §§1317/1317.1state emergency care statutes detailed

No prior authPPACA emergency service protections noted

24-hour

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emergency access requirement

30 minplan response timeframe

3sections listing covered benefits

Coverage Criteria for Emergency and Urgently Needed Services

Emergency medical condition care (EMTALA / HSC)

Covered when ALL of the following are met

Emergency services coverage: Services provided when an emergency medical condition exists or active labor, as defined by statute, are covered and must be provided regardless of payment status; hospitals must perform medical screening exams and stabilize or appropriately transfer patients.

Based on EMTALA and state HSC definitions.

Post-stabilization medical care

Post-stabilization care (California-specific)

Post-stabilization authorization: If an enrollee requires additional medically necessary care after stabilization, the plan must approve or disapprove the provider's request for authorization within 30 minutes; if the plan fails to respond within 30 minutes the requested post-stabilization care is deemed authorized. The plan must pay for medically necessary services to maintain the enrollee's stabilized condition until transfer or discharge is effectuated.30 minutes

All requests and responses must be fully documented, including date/time of request and the names of requesting provider and plan representative.

Emergency and Out-of-Area Urgently Needed Services

Covered when ALL of the following are met

Emergency/Urgent condition: Requested services are medically necessary and meet market-specific definitions of emergency health care or urgently needed services (acute symptoms that would cause a reasonable person to seek immediate care), including psychiatric emergencies and active labor.

Follow Federal/State mandated definitions and State Market Plan Enhancements.

Coverage rationale: Requested services are covered benefits by UnitedHealthcare and are necessary to enable the member to return to the service area or to prevent serious deterioration of the member's condition. For hospitalized members, a coordination plan is required and the treating physician must agree to the plan prior to transfer back to the service area.

Plan may be financially responsible until agreement reached regarding transfer or discharge.

Transportation and transfer: Consensus among the treating physician, the primary care physician or plan specialist, and the plan's medical director is required regarding the member's medical stability for transfer and the proposed transportation method. Refer to the Ambulance Transportation policy for transport modalities.

These rules do not apply to specialized health care service plan contracts that expressly do not provide medically necessary health care services following stabilization. California Health and Safety Code Section 1317 establishes that emergency services and care must be provided at licensed facilities with emergency departments when the patient faces danger of loss of life or serious injury or illness, but the policy’s definition and provision rules are not applicable to specialized plans that exclude post‑stabilization services under applicable state regulation.

Routine follow‑up care, ongoing maintenance therapy, and durable medical equipment are excluded from out‑of‑area emergency coverage. Examples include routine dialysis, routine oxygen, routine laboratory testing, wheelchairs for travel, rehabilitation, skilled nursing care, home health care, and routine imaging or lab work. Additionally, ambulance transport coverage is limited to transport to the nearest facility with appropriate expertise for treating the condition. UnitedHealthcare will not cover services that are part of routine follow‑up or long‑term management when the member is outside the network service area.

Where a specialized health care service plan contract excludes medically necessary services following stabilization, the policy’s post‑stabilization provisions do not apply. In those cases, the plan is not required under this policy to authorize or provide benefits governed by the post‑stabilization rules described elsewhere in this document.

Services that are not medically necessary, services that are not plan covered benefits, or services that could reasonably await the member’s return to the service area without risking serious deterioration or loss of bodily function are not covered. The plan may deny payment when the medical screening examination indicates the enrollee did not require emergency services or when requested out‑of‑area care falls into the non‑covered categories listed above (for example, routine follow‑up, maintenance DME, or care for a stable chronic condition without acute symptoms).

Policy Identifiers, Statutes and Service Coding References

Policy identifiermixed

BIP057.O

Policy identifier — Emergency and Urgent Services

Federal statutes citedmixed

42 U.S.C. §1395dd	EMTALA — Examination and treatment for emergency medical conditions and women in labor
House of Representatives 3590, Section 2719A	Patient Protection and Affordable Care Act (PPACA) emergency services protections

Covered — Ambulance/EMS referencesmixedCovered

911	Emergency response system ambulance services (included in basic health care services)

Post-stabilization authorization response time (CA)

Post-stabilization authorization response time (CA)Plan must approve or disapprove a provider's request for authorization to provide necessary post-stabilization medical care within one half hour (30 minutes) of the request; failure to respond results in deemed authorization.

Deemed authorization conditionIf the plan fails to approve or disapprove within 30 minutes, the post-stabilization care is deemed authorized, subject to limited plan disapproval rights as specified in statute.

ScopeApplies when an enrollee is stabilized but requires additional medically necessary care and the provider requests authorization.

Plan response timeframe

Plan response timeframeWhen contacted by a hospital pursuant to statutory procedure, the plan must, within 30 minutes of the hospital's initial telephone call, either authorize post-stabilization care or inform the hospital it will arrange prompt transfer.

Provider Requirements, Authorization and Documentation

Prior Authorization

Prior authorization prohibition for emergency services

Do not seek prior authorization for emergency services. Under federal PPACA rules and applicable state law, plans may not require prior authorization for emergency services, even if provided by an out-of-network clinician. Attempting to obtain prior authorization prior to or during the provision of emergency screening or stabilization may expose the provider to denial risk—the plan may not withhold payment solely on the basis that prior authorization was not obtained for emergency care.

Prior authorization is prohibited for emergency services
Applies to in-network and out-of-network emergency care

Prior Authorization

Post-stabilization authorization and 30-minute response (CA)

If a treating provider requests authorization for post-stabilization care, the plan must respond rapidly. California law requires the plan to approve or disapprove a request for post-stabilization medical care within 30 minutes of the request; failure to respond within that timeframe deems the care authorized. When a plan elects to transfer instead of authorizing continued care, the plan must effectuate the transfer as soon as possible and is responsible for medically necessary care to maintain stabilization until transfer is effectuated.

Background and Policy Scope

An emergency medical condition is an acute set of symptoms of sufficient severity that, without immediate medical attention, the patient’s health could be placed in serious jeopardy, result in serious impairment of bodily functions, or cause serious dysfunction of any bodily organ or part. Under applicable statute and federal regulation (EMTALA and California Health and Safety Code), hospitals with emergency departments must perform an appropriate medical screening examination and provide emergency services and care when such a condition exists, without regard to payment status. The treating clinician determines whether a patient is stabilized — generally when, in the clinician’s opinion, no material deterioration is likely to result from release or transfer — and stabilization guides subsequent coverage, transfer, and post‑stabilization obligations.

Key Definitions

Emergency medical condition — definition summary

Definition (summary)An 'emergency medical condition' is a medical condition with acute symptoms of sufficient severity that absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy, cause serious impairment to bodily functions, or serious dysfunction of any bodily organ or part (includes active labor).

Includes active laborActive labor means there is inadequate time to safely transfer prior to delivery or transfer would threaten the health and safety of the member or fetus.

Legal basisDefined and required by EMTALA (42 U.S.C. §1395dd) and state regulations; hospitals must perform an appropriate medical screening exam and stabilize or appropriately transfer patients regardless of payment status.

Stabilized / Stabilization — definition summary

Stabilized (summary)A patient is 'stabilized' when, in the opinion of the treating physician (or appropriate licensed persons under supervision), the patient's condition is such that, within reasonable medical probability, no material deterioration is likely to result from release or transfer.

Policy Summary

PayerUnitedHealthcare

PolicyEmergency and Urgent Services

Policy CodePolicy BIP057.O

Change TypeRevisions to California statutory language and updated reference links

Effective DateFeb 1, 2026

Next Review Date

Key ActionDo not require prior authorization for emergency services; for post-stabilization care in California, respond to authorization requests within 30 minutes or care is deemed authorized.

SourceLink

On This Page

Post-stabilization authorization: Plan must authorize post-stabilization care or arrange prompt transfer within 30 minutes of the initial hospital contact; the plan reimburses the hospital if it authorizes care, fails to respond within the timeframe (deemed authorization), or there is an unreasonable delay and a noncontracting physician determines post-stabilization care is required.30 minutes

Plan may require prior authorization for care following stabilization where permitted; exceptions under federal/state law apply.

Reimbursement consequencesPlan must reimburse the hospital for post-stabilization care if it authorizes care, fails to respond within the 30-minute timeframe, or there is an unreasonable delay and a noncontracting physician determines post-stabilization care is required.

Call limitationsThe plan may not require the hospital or noncontracting physician to make more than one telephone call to the number the plan provided in advance.

Plan must approve/disapprove post-stabilization requests within 30 minutes
If plan fails to respond within 30 minutes, post-stabilization care is deemed authorized
If plan denies and arranges transfer, plan must effectuate transfer promptly and pay for care until transfer

Documentation Required

Post-stabilization authorization and documentation (CA)

Providers must document all requests for authorization and the plan's responses. Documentation of post-stabilization authorization requests must include the date/time of the request, the name of the requesting provider, the name of the plan representative responding, and the plan’s decision. All provision of medically necessary services must be fully documented.

Record date and time of the authorization request
Record name of requesting provider and plan representative
Retain the plan's written/telephonic response and decision details

Note

Transportation consensus for transfer

Transportation method for transfers must be agreed by consensus. For out-of-area hospitalizations and transfers, determine the transportation method with agreement among the treating physician, the member's PCP or plan specialist, and the plan's medical director. The treating physician must agree to the plan's proposed coordination plan prior to transfer when the member is hospitalized; if no agreement, a network physician may assume care to authorize transfer.

Consensus required among treating physician, PCP/plan specialist, and plan medical director for transfer method
If treating physician does not agree, network physician with hospital privileges should assume care when feasible

Documentation Required

Transfer documentation required

Transfer and medical records requirements — include a Transfer Summary and all pertinent records. California law requires that all pertinent medical records and diagnostic results reasonably available accompany the patient. The transferring hospital must provide a Transfer Summary signed by the transferring physician containing, at minimum, patient identifiers, insurance status, medical condition, transferring and receiving physician names and times/dates of consent and transfer, reason for transfer, and a declaration that transfer creates no medical hazard.

Include copies of pertinent medical records and diagnostic test results with the transfer
Transfer Summary must be signed by transferring physician and include required minimum elements (patient demographics, insurance status, medical condition, times/dates, names, reason for transfer, declaration of no medical hazard)

Denial Risk

Payment for emergency services may be denied only in limited circumstances

Payment denial conditions and documentation risks. Payment for emergency services may be denied only if the plan reasonably determines the emergency services were never performed. A plan may deny reimbursement for a medical screening exam when the enrollee did not require emergency services and reasonably should have known an emergency did not exist. Additionally, payment for post-stabilization care may be withheld only consistent with statutory rules (e.g., timely notice prior to discontinuation, or if plan properly assumes responsibility and effectuates transfer).

Denials permitted when services were not performed
Denials permitted for screening exams when enrollee reasonably should have known no emergency existed
Plans must follow statutory notice and transfer procedures before denying payment for post-stabilization care

Billing Rule

PROVIDER ACTIONS — operational checklist

Provider operational checklist (actions to take): document all requests and responses; do not delay emergency screening or stabilization to seek prior authorization; if requesting post-stabilization authorization, note exact date/time and the plan representative name and obtain written or telephonic confirmation; ensure Transfer Summary and all pertinent records accompany any transfer; obtain and document consensus on transportation method when required.

Do not delay emergency care to obtain prior authorization
Document date/time, requester, and plan responder for all authorization contacts
If transfer occurs, include Transfer Summary and copies of diagnostic tests and records
Confirm and document consensus among treating physician, PCP/plan specialist, and plan medical director for transport

Clinical implicationStabilization determines whether post-stabilization authorization rules and transfer requirements apply.

Reference statuteDefined in California Health & Safety Code Section 1317.1(j).

Psychiatric emergency medical condition — definition summary

Psychiatric emergency definition (summary)A 'psychiatric emergency medical condition' is a mental health disorder with acute symptoms severe enough to render the patient an immediate danger to themselves or others, or immediately unable to provide for or use food, shelter, or clothing due to the disorder.

Care scopeMay include admission or transfer to a psychiatric unit or acute psychiatric hospital when necessary and within facility capability, subject to applicable laws.

Applies regardless of detention statusDefinition applies whether the patient is voluntary or involuntarily detained for assessment, evaluation, crisis intervention, or placement under applicable statutes.

Stabilized / stabilization — alternate/expanded definition (treating physician or licensed person)

Expanded stabilization definition'Stabilized' means that, in the opinion of the treating physician or other appropriate licensed persons acting within their scope under supervision, the patient's condition is such that, within reasonable medical probability, no material deterioration is likely to result from release or transfer; applicable to determinations made by treating clinicians and supervised licensed persons.

Who may determine stabilizationThe treating physician and surgeon, or other appropriate licensed persons acting within their scope under the supervision of a treating physician and surgeon, may determine stabilization.

LimitationsThis definition does not expand the scope of licensure for licensed persons providing services under the statute.

Consultation — definition including remote opinion/advice and hospitalization/transfer decisions

Consultation (summary)'Consultation' means rendering an opinion or advice, prescribing treatment, or making a decision regarding hospitalization or transfer by telephone or other means of communication; when medically necessary and jointly determined, it includes review of records, in-person examination, and treatment by the consulting physician or other appropriate licensed person.

Request and responsibilityA request for consultation must be made by the treating physician or appropriate licensed persons with contemporaneous approval of the treating physician; the consulting physician is ultimately responsible for providing the necessary consultation regardless of who makes the in-person appearance.

When in-person consult occursIn-person examination and treatment by the consultant occur when jointly determined medically necessary by the treating and consulting physicians (or appropriate licensed persons acting within their scope), and the consultant is qualified to give the opinion or render necessary treatment to stabilize the patient.