Emergency Services

When Health Plan members present in your emergency room for treatment, we expect you to triage and treat them in accordance with EMTALA requirements, and to contact Kaiser Permanente’s Emergency Prospective Review Program (EPRP) once the member has been stabilized or stabilizing care has been initiated.

Emergency Prospective Review Program (EPRP)
1-800-447-3777
Available 7 days a week
24 hours a day

You may contact EPRP at any time, including prior to stabilization to the extent legally and clinically appropriate, to receive relevant, member-specific medical history information which may assist you in your stabilization efforts and any subsequent post-stabilization care. EPRP has access to member medical history, including recent test results, which can help expedite diagnosis and inform further care.

In addition, EPRP can authorize post-stabilization care at your facility, as required under each member’s Evidence of Coverage in order for non-emergency care to be a covered benefit, or assist in making other appropriate care arrangements.

EPRP provides:

• Access to clinical information 24 hours a day, every day of the year, to help you in evaluating a member’s condition and to enable our physicians, and the treating physicians at your facility, to quickly determine the appropriate treatment for the member.
• Emergency-physician-to-emergency-physician discussion regarding a member’s case 24 hours a day, every day of the year.
• Authorization of post-stabilization care, 24 hours a day, every day of the year, or assistance with making appropriate alternative care arrangements.

Please note: Under the EMTALA regulations issued September 2003, providers may, but are not required to, contact EPRP once stabilizing care has been initiated but prior to the member’s actual stabilization, if such contact will not delay necessary care or otherwise harm the member.

EPRP provides a statewide emergency services notification system in California for all Health Plan members. It also provides authorization for requested post-stabilization care and must be contacted prior to a stabilized Health Plan member’s admission to your facility, unless your agreement establishes a different process.

The health of our members comes first. When members present in your emergency room for treatment, we expect you to triage and treat them in accordance with EMTALA requirements. Once the member has been stabilized or stabilizing care has been initiated, contact Kaiser Permanente’s Emergency Prospective Review Program (EPRP).

Emergency Prospective Review Program (EPRP)
1-800-447-3777
Available 7 days a week
24 hours a day

EPRP provides a statewide emergency services notification system in California for providers to use related to such services to all Kaiser Permanente members. It also provides authorization for requested post-stabilization care and must be contacted prior to a stabilized member’s admission to your facility, unless your agreement establishes a different process.

Please note: Under the EMTALA regulations issued September 2003, providers may, but are not required to, contact EPRP once stabilizing care has been initiated but prior to the member’s actual stabilization, if such contact will not delay necessary care or otherwise harm the member.

EPRP will authorize post-stabilization care at your facility, as required under the member’s Evidence of Coverage, or assist in making other appropriate care arrangements. For non-emergency care to be covered as a benefit, EPRP authorization is required.

If there is mutual agreement about your organization providing post-stabilization services, EPRP will authorize you to provide the agreed-upon services and give you an authorization number. At your request, EPRP will also provide a written confirmation of the services authorized and the confirmation number by fax or other electronic means.

Note: The authorization number must be included with the claim for payment for the authorized services. In addition:

• You must provide all reasonably relevant information relating to the post-stabilization services on your claim submission consistent with the information provided to EPRP as the basis for the authorization; and
• EPRP must have confirmed that the member was eligible for and had benefit coverage for the authorized post-stabilization services provided.
  If EPRP authorizes the admission of a clinically stable member to your facility, Kaiser Permanente’s Outside Services Case Manager will follow that member’s care in your facility, including any authorization of subsequent care, until discharge or transfer.

If the member is admitted to your facility as part of the stabilizing process and you have not yet been in contact with EPRP, you must contact your local case management department in order to discuss authorization for continued admission as well as any additional appropriate post-stabilization care once the member’s condition is stabilized.

Please note:

• EPRP may deny authorization for some or all post-stabilization services. The verbal denial of authorization will be confirmed to you in writing.
• EPRP may request that the member be transferred to a Kaiser Permanente-designated facility for continuing care or EPRP may authorize certain post-stabilization services in your facility on the condition that such services be rendered under the management of a physician who is a member of your facility’s medical staff and who has contracted with Kaiser Permanente to manage the care of our members being treated in community hospitals.
• If EPRP denies authorization for requested post-stabilization care, Kaiser Permanente has no financial responsibility if you nonetheless choose to provide the care.
• If the member insists on receiving such unauthorized post-stabilization care from your facility, we strongly recommend that you require that the member sign a financial responsibility form acknowledging and accepting his or her sole financial liability for the cost of the unauthorized post-stabilization care and/or services.
  

Note: If the member wishes to discuss the process of filing a claim with Kaiser Permanente, please refer the member to Kaiser Permanente’s Member Services Department at 800-464-4000. A member services representative will explain the claims process to the member.