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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-511. Medicaid Accountable Care Organization Incentives to Appropriately Use Emergency Room Services |
R414-511-2. Definitions
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(1) "Non-emergent medical condition" means a medical condition that does not meet the criteria of an emergency medical condition under 42 U.S.C. 1395dd (e) of the Emergency Medical Treatment and Active Labor Act.
(2) "Non-emergent medical care" means:
(a) Medical care provided in an emergency room for the treatment of a non-emergent medical condition.
(3) "Non-emergent medical care" does not mean:
(a) Medical services necessary to conduct a medical screening examination to determine if the Medicaid beneficiary has an emergent or non-emergent medical condition; and
(b) Medical care provided to a Medicaid beneficiary who, using a prudent layperson standard, reasonably believes he is experiencing an "emergency medical condition" as defined by 42 U.S.C. 1395dd(e) of the Emergency Medical Treatment and Active Labor Act.
(4) "Medicaid Beneficiary" means a person who enrolls in an ACO in accordance with the Department's "Choice of Health Care Delivery Program" (CHCDP) freedom-of-choice waiver under Section 1915(b) of the Social Security Act.