The Two-Part Test: When a Hospital Visit Triggers EMTALA Obligation (42 U.S.C. § 1395dd(a))

The federal EMTALA screening obligation turns on a two-part test in 42 U.S.C. § 1395dd(a): (1) the individual comes to the emergency department, and (2) a request is made for examination or treatment. When both parts are met, the hospital must provide an appropriate medical screening examination (MSE) within its capability. Regulations at 42 CFR § 489.24(a) and definitions in § 489.24(b) make clear that “coming to the ED” includes requests for help made anywhere on hospital property or at a dedicated emergency department (DED). For small hospitals, getting this trigger right is the difference between clean compliance and survey findings, penalties, and reputational damage. The safest approach is to operationalize the two-part test as soon as the first request for medical attention is voiced, no matter where on campus it occurs.

EMTALA exists to ensure that anyone who seeks emergency care receives a timely MSE and, if an emergency medical condition (EMC) is found, stabilizing treatment or appropriate transfer. The law does not hinge on insurance status, clinical appearance, or desk location. It focuses on arrival plus request. Hospitals with lean staffing must make this threshold both unmistakable and easy to execute. This article distills the legal trigger from 42 U.S.C. § 1395dd(a) and 42 CFR § 489.24(a)–(b) into a practical arrival protocol, aligning greeters, security, registrars, and clinicians so the MSE pathway begins the instant the two-part test is met.

Legal Framework & Scope Under 42 U.S.C. § 1395dd(a)

The statutory two-part test. The statute requires that a Medicare-participating hospital with an emergency department provide an MSE if:

1. An individual comes to the emergency department, and

2. A request is made for examination or treatment for a medical condition.
   When these are satisfied, the hospital must perform an appropriate MSE to determine whether an EMC exists (42 U.S.C. § 1395dd(a)). If an EMC is identified, stabilization or appropriate transfer must follow (§ 1395dd(b)–(c)).

How regulations make the test operational. The implementing rule at 42 CFR § 489.24(a) adopts the statutory trigger and is read with § 489.24(b) to interpret where and when someone has “come to the ED.” Key definitions include:

• Dedicated emergency department (DED): A licensed ED or a department that holds itself out as providing emergency care or meets visit thresholds for emergency conditions.

• Hospital property/campus: Buildings, sidewalks, driveways, and parking areas owned or operated by the hospital.
  Thus, a request made on hospital property, even in a parking lot, meets the “comes to the ED” prong. The request may be explicit (“I need help”) or made on the person’s behalf.

Federal floor, not ceiling. States can impose additional patient access protections but cannot narrow EMTALA’s federal trigger. Policies that screen for insurance before initiating MSE undermine the statute and will not excuse delay.

Compliance payoff. Understanding this framework separates three distinct duties: screening (triggered by arrival and request), stabilization/transfer (only after EMC is found), and documentation (proving timeliness and non-interference). Clarity here reduces denials, accelerates care, and minimizes survey risk.

CMS oversees investigations (often via state survey agencies), issues deficiency statements, and requires corrective actions when the two-part test is missed. OIG may impose civil monetary penalties for EMTALA violations. Typical triggers include complaints about:

• Patients redirected from lobbies, parking areas, or off-campus DEDs without initiating the MSE pathway.

• Finance or registration steps occurring before any MSE action.

• Hospital-owned ambulance decisions that effectively circumvent the two-part test by bypassing the ED without a lawful diversion or prior acceptance elsewhere.

• Non-ED portals (e.g., labor and delivery, imaging, behavioral health) that fail to treat symptom-driven requests as ED arrivals.
   Bottom line: When CMS reconstructs the timeline, it looks for a first request time stamp, a rapid MSE initiation, and the absence of insurance-related delay, benchmarks that flow directly from § 1395dd(a) and § 489.24(a).

Lean teams need crisp, repeatable steps that bind to the statutory two-part test. Each control below ties directly to 42 U.S.C. § 1395dd(a) (arrival + request) and the operational definitions in 42 CFR § 489.24(a)–(b).

Control 1. Two-Part Test Card and 10-Second Script

• Implement: Issue a pocket card to security, greeters, registrars, transporters, and volunteers:

  • Two-Part Test: “On hospital property or a DED + request for medical exam/treatment = start MSE.”

  • Script: “You are at the hospital. If you need a medical exam or treatment, I will contact the emergency team now.” Activate ED intake immediately.

• Evidence: Card distribution list, sign-off sheets, and posted scripts at entrances.

• Low-cost: Single page laminated; reviewed in daily huddles.

• Authority: Immediate initiation aligns with § 1395dd(a) and § 489.24(a).

Control 2. First-Request Time Stamp & ED Relay

• Implement: Equip first-contact roles with a one-tap time-stamp (mobile form or desk button) that alerts the ED charge nurse with location.

• Evidence: System audit logs; ED log entries recording receipt and response time.

• Low-cost: Use existing EHR quick actions or a shared form tool.

• Authority: Documents the precise moment the request occurred, under § 1395dd(a).

Control 3. Finance Firewall

• Implement: Prohibit insurance or payment questions until after ED activation. Where immediate identifiers are needed for safety, limit to name and chief complaint.

• Evidence: Registration policy; audit of random encounters confirming MSE steps preceded finance steps.

• Low-cost: Pocket card reminders; quarterly spot checks.

• Authority: Prevents interference with the screening duty mandated by § 1395dd(a) and reflected in § 489.24(a).

Control 4. Campus Trigger Map and Call Points

• Implement: Mark “EMTALA trigger zones” (parking lots, sidewalks, lobbies, DED doors, L&D entrance). Place “Emergency help here” placards with a direct number or QR call to the ED.

• Evidence: Photo inventory; monthly call-through tests with results logged.

• Low-cost: In-house signage; QR stickers.

• Authority: Aligns property-based triggers with § 489.24(b) and the statutory arrival prong.

Control 5. Portal Protocols (L&D, Imaging, BH, Clinics)

• Implement: Any symptomatic individual requesting help at a non-ED portal is treated as an ED arrival; either ED comes to bedside or the patient is escorted to ED without delay.

• Evidence: Call logs to ED; transfer times from portal to triage.

• Low-cost: Single extension or panic button to ED nurse desk; brief portal staff quarterly.

• Authority: Treats on-campus requests as triggers under § 1395dd(a) and § 489.24(a).

Control 6. Ambulance Decision Tree

• Implement:

• • Hospital-owned ambulance: Default to transport to your ED when a request for care exists, unless lawful diversion is active or another ED has accepted the patient.

  • 9-1-1 ambulance on property: Arrival equals ED presentation; initiate MSE unless appropriate bypass is in effect and documented.

• Evidence: Radio logs matched to ED activation times; diversion memos.

• Low-cost: One-page algorithm posted in EMS room; quarterly joint huddle with EMS.

• Authority: Reinforces arrival + request logic in § 1395dd(a) as applied through § 489.24(a).

Control 7. “Declined Examination” Documentation

• Implement: If someone refuses after you offer an MSE, use a smart phrase capturing the offer, the patient’s words, understanding of risk, and how to reaccess ED.

• Evidence: Encounter notes; refusal acknowledgments when feasible.

• Low-cost: Add smart phrase to the EHR triage module.

• Authority: Clarifies whether and when the statutory request occurred.

Control 8. Rapid Clinician Touchpoint Metric

• Implement: Track “first request to first clinician assessment” median time for campus, lobby, parking lot, and portal-origin cases.

• Evidence: Monthly dashboard; variance analysis and corrective actions.

• Low-cost: Simple spreadsheet fed by ED log exports.

• Authority: Demonstrates functional compliance with § 1395dd(a).

Case Study

Scenario: A 62-year-old arrives in a ride-share and asks the valet, “Where do I go for chest pain?” The valet gestures to registration inside. The patient slowly walks in; triage begins 12 minutes later. Later, a complaint alleges EMTALA delay.

Analysis under the two-part test:

• Part 1 (arrival): The patient is on hospital property (driveway/entrance), which is part of the campus.

• Part 2 (request): The patient verbally requested help for a medical problem (“chest pain”).
   The duty to provide an MSE attached at the driveway under 42 U.S.C. § 1395dd(a), operationalized by 42 CFR § 489.24(a)–(b). The valet’s redirection without ED activation created delay.

Playbook impact: With Control 1 and Control 2, the valet would have used the 10-second script and hit the time-stamp, notifying the charge nurse; Control 4 signage would have provided an immediate call point; Control 3 would have prevented any finance step from intervening. The record would show a driveway request time, ED activation within seconds, and triage well before the 12-minute mark. The hospital avoids a citation, and the patient receives faster care.

Wrap-up: These tasks prove that the two-part test is recognized and acted upon in real time, producing contemporaneous evidence that satisfies § 1395dd(a) and § 489.24(a) expectations.

Risk Traps & Fixes Under 42 U.S.C. § 1395dd(a)

Before listing fixes, note that each trap centers on missing either arrival or request within the operational definitions of § 489.24(b).

• Trap: Treating “arrival” as “triage desk only,” ignoring lobbies or parking lots.
   Fix: Use campus maps and scripts that convert any on-property request to ED activation. This aligns with the arrival prong under § 1395dd(a) and § 489.24(a).

• Trap: Asking for insurance before activating the MSE pathway.
   Fix: Enforce the finance firewall so nothing precedes MSE steps required by § 1395dd(a); audit for violations.

• Trap: Valet/greeter redirection to urgent care or PCP without ED involvement.
   Fix: First offer is always ED evaluation; alternatives follow only after an MSE or documented refusal, preserving the request prong in § 1395dd(a).

• Trap: Off-campus confusion, assuming provider-based clinics trigger EMTALA.
   Fix: Maintain a roster distinguishing DEDs from non DED clinics. Apply ED arrival rules only at DEDs and on campus per § 489.24(b), while still calling 9-1-1 for emergencies.

• Trap: Ambulance bypass without lawful diversion or acceptance elsewhere.
   Fix: Standardize a written decision tree capturing acceptance, diversion status, and destination, reflecting § 1395dd(a) expectations.

• Trap: Poor evidence trails.
   Fix: Time-stamp first requests and reconcile security/EMS/ED logs monthly to show timely activation.

Wrap-up: These fixes turn the two-part test into immediate action and defensible documentation, significantly lowering exposure under § 1395dd(a) and § 489.24(a).

Ownership: The ED Medical Director owns the policy text for the two-part test and the MSE standard; the ED Nurse Manager owns daily execution and metrics; the Security Chief owns first-contact scripting and wheelchair deployment; the Registration Supervisor owns the finance firewall; the Facilities Director owns signage and call points; and the EMS Liaison owns radio protocol alignment.

Cadence:

• Monthly: Review median time from first request to ED activation; validate call-point function; reconcile EMS and ED logs.

• Quarterly: Drill portals; refresh scripts and pocket cards; report to the Medical Executive Committee.

• Annually: Policy update to reflect any regulatory guidance; leadership attestations.

Simple metrics: (1) Percent of encounters with a recorded first-request time; (2) median minutes from first request to clinician contact; (3) number of misroutes (redirects without ED activation). These measures give leaders a fast read on whether the two-part test is being applied where patients actually arrive.

The EMTALA screening duty is neither vague nor discretionary. It turns on two clear conditions in 42 U.S.C. § 1395dd(a): arrival at the ED (including hospital property/DED) and a request for care. When both occur, the hospital must begin an appropriate MSE, immediately and without finance-related delay, under 42 CFR § 489.24(a). Small hospitals can meet this standard with inexpensive tools and consistent habits: a pocket card, a time-stamp, a call point, and a firewall against premature registration questions.

Immediate next steps:

1. Distribute the two-part test pocket card and teach the 10-second script to every first-contact role.

2. Turn on first-request time-stamping with automatic alerts to the ED charge nurse.

3. Post “Emergency help here” placards and test call points across all trigger zones.

4. Enforce the finance firewall with spot audits and corrective coaching.

5. Run a cross-department drill (L&D, imaging, BH, security, registration) to validate the end-to-end pathway from request to clinician touchpoint.

Strengthening compliance isn’t just about checking boxes. A compliance platform helps your practice stay ahead by tracking regulatory requirements, running proactive risk assessments, and keeping you audit-ready, proving to patients and regulators that you prioritize accountability.

• United States Code: 42 U.S.C. § 1395dd — Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)
  

• eCFR: 42 CFR § 489.24 — Special Responsibilities of Medicare Hospitals in Emergency Cases (including § 489.24(a))
  

• CMS State Operations Manual, Appendix V — Interpretive Guidelines for EMTALA
  

• Office of Inspector General — EMTALA Civil Monetary Penalties Overview