PROVIDER REQUIREMENTS. The State Programs, through contractual requirements and federal and State statutes and regulations, require the Agreement to contain certain requirements with which Health Plan and Subcontractor must comply, including the following: 3.1 Provider shall follow the State Contracts’ provisions for the coverage of Covered Services. Provider’s decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions: (a) Emergency Medical Condition: A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in any of the following: (1) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a pregnant woman, the health of the woman or her unborn child or, in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; (2) serious impairment to such person’s bodily functions; (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.
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Sources: Regulatory Requirements Appendix, Regulatory Requirements Appendix
PROVIDER REQUIREMENTS. The State Programs, through contractual requirements and federal and State statutes and regulations, require the Agreement to contain certain requirements with which Health Plan United and Subcontractor Provider must comply, including the following:
3.1 Provider shall follow the State Contracts’ provisions for the coverage of Covered Services. Provider’s decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions:
(a) Emergency Medical Condition: A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in any of the following: (1) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a pregnant woman, the health of the woman or her unborn child or, in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; (2) serious impairment to such person’s bodily functions; (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.
Appears in 1 contract
Sources: Regulatory Requirements Appendix