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§ 764m. Billing

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: January 1, 2016

Purdon's Pennsylvania Statutes and Consolidated Statutes
Title 40 P.S. Insurance (Refs & Annos)
Chapter 2. Insurance Companies (Refs & Annos)
Article VI. Casualty Insurance (Refs & Annos)
(b) Health and Accident Insurance (Refs & Annos)
Effective: January 1, 2016
40 P.S. § 764m
§ 764m. Billing
(a) When an EMS agency is dispatched by a public safety answering point as defined in 35 Pa.C.S. § 5302 (relating to definitions) or an EMS agency dispatch center under 35 Pa.C.S. § 8129(i) (relating to emergency medical services agencies) for an emergency and provides medically necessary emergency medical services, a payment made by an insurer for a claim covered under and in accordance with a health insurance policy for an emergency medical service performed by the EMS agency during the call shall be paid directly to the EMS agency.
(b) An insurer must reimburse a nonnetwork EMS agency under the following:
(1) The EMS agency has submitted a completed standardized form to the department requesting nonnetwork direct reimbursement from an insurer an EMS agency has identified. The form must be submitted to the department annually by October 15. The form shall declare the EMS agency's intention to receive direct payment from an insurer identified on the form for the next calendar year. The department shall develop a standardized form, using an EMS agency's assigned license number, to be used by an EMS agency that meets the conditions established under this section. The department shall develop and maintain a publicly accessible electronic registry that indicates which EMS agency has requested nonnetwork direct reimbursement from an insurer identified on the form.
(2) An EMS agency has provided notification to the insurer upon submitting a claim for reimbursement that the EMS agency is registered with the department to receive direct reimbursement as provided for under this section.
(c) An EMS agency may be subject to periodic audits by an insurer to examine claims for direct reimbursement under this section. If, through the audit, the insurer identifies an improper payment, the insurer may deduct the improper payment from future reimbursements.
(d) Where an insurer has reimbursed a nonnetwork EMS agency at the same rate it has established for a network EMS agency, the EMS agency may not bill the insured directly or indirectly or otherwise attempt to collect from the insured for the service provided, except for a billing to recover a copayment, coinsurance or deductible as specified in the health insurance policy.
(e) An EMS agency that submits a form under this section may solicit donations or memberships or conduct fundraising, except that an EMS agency may not promise, suggest or infer to donors that a donation will result in the donor not being billed directly for any payment as provided under this section. Notwithstanding this paragraph, an EMS agency may bill in accordance with subsection (d). A violation of this section shall be considered a violation of the act of December 17, 1968 (P.L. 1224, No. 387),1 known as the “Unfair Trade Practices and Consumer Protection Law.”
(f) Claims paid under this section shall be subject to section 2166.2
(g) This section shall apply only to an EMS agency that is a nonnetwork provider and provides emergency medical services, unless preempted by Federal law.
(h) As used in this section:
“Department.” Department of Health of the Commonwealth.
“EMS agency.” As defined in 35 Pa.C.S. § 8103 (relating to definitions).
“Emergency medical services.” As defined in 35 Pa.C.S. § 103 (relating to definitions).
“Insurer.” As follows:
(1) An entity that is responsible for providing or paying for all or part of the cost of emergency medical services covered by an insurance policy, contract or plan. The term includes an entity subject to:
(i) section 630,3 Article XXIV4 or any other provision of this act;
(ii) the act of December 29, 1972 (P.L. 1701, No. 364),5 known as the Health Maintenance Organization Act; or
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).
(2) The term does not include an entity that is responsible for providing or paying under an insurance policy, contract or plan which meets any of the following:
(i) Is a homeowner's insurance policy.
(ii) Provides any of the following types of insurance:
(A) Accident only.
(B) Fixed indemnity.
(C) Limited benefit.
(D) Credit.
(E) Dental.
(F) Vision.
(G) Specified disease.
(H) Medicare supplement.
(I) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.
(J) Long-term care.
(K) Disability income.
(L) Workers' compensation.
(M) Automobile medical payment insurance.


1921, May 17, P.L. 682, No. 284, art. VI, § 635.7, added 2015, Dec. 20, P.L. 461, No. 84, § 1, effective Jan. 1, 2016.


73 P.S. § 201-1 et seq.
40 P.S. § 991.2166.
40 P.S. § 764a.
40 P.S. § 991.2401 et seq.
40 P.S. § 1551 et seq.
40 P.S. § 764m, PA ST 40 P.S. § 764m
Current through 2022 Regular Session Act 121. Some statute sections may be more current, see credits for details.
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