Common use of Post-Stabilization Services Clause in Contracts

Post-Stabilization Services. Benefits and services, related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). The Contractor shall cover Post Stabilization Services in accordance with Section 1867 of the Social Security Act. The CONTRACTOR shall: 4.2.11.2.1. Cover benefits and services that may be required subsequent to a stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility. 4.2.11.2.2. Be responsible for payment to Providers—both In- network and out-of-network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Section 1867 (42 U.S.C. 1395 dd). 4.2.11.2.3. Cover Post Stabilization Services that were not pre- approved by the CONTRACTOR because the CONTRACTOR did not respond to the Provider of Post Stabilization Services request for pre-approval within one (1) hour after the request was made. 4.2.11.2.4. Cover Post- Stabilization Services if the CONTRACTOR could not be contacted for pre- approval. 4.2.11.2.5. Cover Post Stabilization Services if the CONTRACTOR and the treating Provider cannot reach an agreement concerning the Member’s care and a network Provider is not available for consultation. In this situation, the CONTRACTOR shall give the treating Provider the opportunity to consult with a CONTRACTOR’s network Provider, and the treating Provider may continue with the care of the Member until a network Provider is reached or one of the criteria of 42 CFR 422.113(c)(3) is met. 4.2.11.2.6. Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR’s network Providers. 4.2.11.2.7. Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. 1395 dd) guidelines and other applicable state and federal regulations. 4.2.11.2.8. Be financially responsible for Post Stabilization Services it has not pre-approved until: 4.2.11.2.8.1. A CONTRACTOR’s network Provider with privileges at the treating hospital assumes responsibility for the Member’s care, 4.2.11.2.8.2. A CONTRACTOR’s network Provider assumes responsibility for the Member’s care through transfer, 4.2.11.2.8.3. A CONTRACTOR’s representative and the treating Provider reach an agreement concerning the Member’s care, 4.2.11.2.8.4. The Member is discharged.

Post-Stabilization Services. Benefits and services, related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). 3.4.6.2.1 The Contractor shall cover Post Stabilization Services in accordance with Section 1867 Services, pursuant to 42 CFR 438.114(e) and 42 CFR 422.113(c)(2) without requiring authorization, and regardless of whether the member obtains the services within or outside the Contractor’s provider network if any of the Social Security Act. The CONTRACTOR shallfollowing circumstances exist: 4.2.11.2.1. Cover benefits and services that may be required subsequent to a stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility. 4.2.11.2.2. Be responsible for payment to Providers—both In- network and out-of-network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Section 1867 (42 U.S.C. 1395 dd). 4.2.11.2.3. Cover 3.4.6.2.1.1 The Post Stabilization Services that were pre- approved by the Contractor; 3.4.6.2.1.2 The Post Stabilization Services were not pre- approved by the CONTRACTOR Contractor because the CONTRACTOR Contractor did not respond to the Provider of provider’s request for these Post Stabilization Services request for pre-approval within one (1) hour after of the request was made.request; 4.2.11.2.4. Cover Post- 3.4.6.2.1.3 The Post Stabilization Services if were not pre- approved by the CONTRACTOR Contractor because the Contractor could not be contacted reached by the provider to request pre- approval for pre- approval. 4.2.11.2.5. Cover these Post Stabilization Services if the CONTRACTOR Services; or 3.4.6.2.1.4 The Contractor’s representative and the treating Provider physician cannot reach an agreement concerning the Membermember’s care and a network Provider participating provider is not available for consultation. In this situation, the CONTRACTOR shall Contractor must give the treating Provider physician the opportunity to consult with a CONTRACTOR’s network Provider, participating provider and the treating Provider physician may continue with the care of the Member patient until a network Provider participating provider is reached or one of the criteria of in 42 CFR 422.113(c)(3) is met. 4.2.11.2.6. Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR3.4.6.2.2 The Contractor’s network Providers. 4.2.11.2.7. Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. 1395 dd) guidelines and other applicable state and federal regulations. 4.2.11.2.8. Be financially responsible financial responsibility for Post Stabilization Services it has that have not been pre-approved until: 4.2.11.2.8.1. A CONTRACTOR’s network Provider shall end when: (i) a participating provider with privileges at the treating hospital assumes responsibility for the Membermember’s care, 4.2.11.2.8.2. A CONTRACTOR’s network Provider ; (ii) a participating provider assumes responsibility for the Membermember’s care through transfer, 4.2.11.2.8.3. A CONTRACTOR’s ; (iii) a representative of the Contractor and the treating Provider physician reach an agreement concerning the Membermember’s care, 4.2.11.2.8.4. The Member ; or (iv) the member is discharged. 3.4.6.2.3 The Contractor must limit charges to members for Post Stabilization Services received from non-participating providers to an amount no greater than what the Contractor would have charged the member if he/she she obtained the services from a participating provider.

Post-Stabilization Services. Benefits and services, related to an Emergency Medical Condition that are provided after an Enrollee a Member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). The Contractor shall cover Post Stabilization Services in accordance with Section 1867 of the Social Security Act, 42 CFR § 438.114(e) and 42 CFR § 422.113(c)(3)(i) - (iv). The CONTRACTOR shall: 4.2.11.2.1. 4.2.12.2.1 Cover benefits and services that may be required subsequent to a the stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility. 4.2.11.2.2. 4.2.12.2.2 Be responsible for payment to Providers—— both In- In-network and out-of-of- network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Act Section 1867 (42 U.S.C. § 1395 dd). 4.2.11.2.3. 4.2.12.2.3 Cover Post Stabilization Services that were not pre- pre-approved by the CONTRACTOR because the CONTRACTOR did not respond to the Provider of Post Stabilization Services request for pre-approval within one (1) hour after the request was made. 4.2.11.2.4. 4.2.12.2.4 Cover Post- Stabilization Services if the CONTRACTOR could not be contacted for pre- pre-approval. 4.2.11.2.5. 4.2.12.2.5 Cover Post Stabilization Services if the CONTRACTOR and the treating Provider cannot reach an agreement concerning the Member’s care and a network an In Network Provider is not available for consultation. In this situation, the CONTRACTOR shall give the treating Provider the opportunity to consult with a CONTRACTOR’s network In Network Provider, and the treating Provider may continue with the care of the Member until a network Provider is reached or one of the criteria of 42 CFR § 422.113(c)(3) is met. 4.2.11.2.6. 4.2.12.2.6 Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR’s network In Network Providers. 4.2.11.2.7. 4.2.12.2.7 Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. § 1395 dd) guidelines and other applicable state and federal regulations. 4.2.11.2.8. Be financially responsible for Post Stabilization Services it has not pre-approved until: 4.2.11.2.8.1. A CONTRACTOR’s network Provider with privileges at the treating hospital assumes responsibility for the Member’s care, 4.2.11.2.8.2. A CONTRACTOR’s network Provider assumes responsibility for the Member’s care through transfer, 4.2.11.2.8.3. A CONTRACTOR’s representative and the treating Provider reach an agreement concerning the Member’s care, 4.2.11.2.8.4. The Member is discharged.

Post-Stabilization Services. Benefits and services, related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). The Contractor shall cover Post Stabilization Services in accordance with Section 1867 of the Social Security Act, 42 CFR § 438.114(e) and 42 CFR § 422.113(c)(3)(i) - (iv). The CONTRACTOR shall: 4.2.11.2.1. 4.2.12.2.1 Cover benefits and services that may be required subsequent to a stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility. 4.2.11.2.2. 4.2.12.2.2 Be responsible for payment to Providers—— both In- In-network and out-of-network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Act Section 1867 (42 U.S.C. § 1395 dd). 4.2.11.2.3. 4.2.12.2.3 Cover Post Stabilization Services that were not pre- approved by the CONTRACTOR because the CONTRACTOR did not respond to the Provider of Post Stabilization Services request for pre-approval within one one (1) hour after the request was made. 4.2.11.2.4. 4.2.12.2.4 Cover Post- Post Stabilization Services if the CONTRACTOR could not be contacted for pre- pre-approval. 4.2.11.2.5. 4.2.12.2.5 Cover Post Stabilization Services if the CONTRACTOR and the treating Provider cannot reach an agreement concerning the Member’s care and a network an In Network Provider is not available for consultation. In this situation, the CONTRACTOR shall give the treating Provider the opportunity to consult with a CONTRACTOR’s network In Network Provider, and the treating Provider may continue with the care of the Member until a network Provider is reached or one of the criteria of 42 CFR § 422.113(c)(3) is met. 4.2.11.2.6. 4.2.12.2.6 Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR’s network In Network Providers. 4.2.11.2.7. 4.2.12.2.7 Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. § 1395 dd) guidelines and other applicable state and federal regulations. 4.2.11.2.8. 4.2.12.2.8 Be financially responsible for Post Stabilization Services it has not pre-pre- approved until: 4.2.11.2.8.1. 4.2.12.2.8.1 A CONTRACTOR’s network In Network Provider with privileges at the treating hospital assumes responsibility for the Member’s care, 4.2.11.2.8.2. 4.2.12.2.8.2 A CONTRACTOR’s network In Network Provider assumes responsibility for the Member’s care through transfer, 4.2.11.2.8.3. 4.2.12.2.8.3 A CONTRACTOR’s representative and the treating Provider reach an agreement concerning the Member’s care, 4.2.11.2.8.4. The Member is discharged.

Post-Stabilization Services. Benefits and services, related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). The Contractor shall cover Post Stabilization Services in accordance with Section 1867 of the Social Security Act. The CONTRACTOR shall: 4.2.11.2.1. 4.2.12.2.1 Cover benefits and services that may be required subsequent to a stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility. 4.2.11.2.2. 4.2.12.2.2 Be responsible for payment to Providers—— both In- In-network and out-of-network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Act Section 1867 (42 U.S.C. 1395 dd). 4.2.11.2.3. 4.2.12.2.3 Cover Post Stabilization Services that were not pre- approved by the CONTRACTOR because the CONTRACTOR did not respond to the Provider of Post Stabilization Services request for pre-approval within one one (1) hour after the request was made. 4.2.11.2.4. 4.2.12.2.4 Cover Post- Stabilization Services if the CONTRACTOR could not be contacted for pre- pre-approval. 4.2.11.2.5. 4.2.12.2.5 Cover Post Stabilization Services if the CONTRACTOR and the treating Provider cannot reach an agreement concerning the Member’s care and a network an In Network Provider is not available for consultation. In this situation, the CONTRACTOR shall give the treating Provider the opportunity to consult with a CONTRACTOR’s network In Network Provider, and the treating Provider may continue with the care of the Member until a network Provider is reached or one of the criteria of 42 CFR 422.113(c)(3) is met. 4.2.11.2.6. 4.2.12.2.6 Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR’s network In Network Providers. 4.2.11.2.7. 4.2.12.2.7 Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. 1395 dd) guidelines and other applicable state and federal regulations. 4.2.11.2.8. 4.2.12.2.8 Be financially responsible for Post Stabilization Services it has not pre-pre- approved until: 4.2.11.2.8.1. 4.2.12.2.8.1 A CONTRACTOR’s network In Network Provider with privileges at the treating hospital assumes responsibility for the Member’s care, 4.2.11.2.8.2. 4.2.12.2.8.2 A CONTRACTOR’s network In Network Provider assumes responsibility for the Member’s care through transfer, 4.2.11.2.8.3. 4.2.12.2.8.3 A CONTRACTOR’s representative and the treating Provider reach an agreement concerning the Member’s care, 4.2.11.2.8.4. The Member is discharged.