Common use of Certification of Emergency Admissions Clause in Contracts

Certification of Emergency Admissions. When a Member requires an emergency admission to a Hospital, Psychiatric Hospital, Rehabilitation Hospital, Residential Treatment Facility or Substance Abuse Treatment Facility, benefits for Covered Services will be provided subject to the following: a. In-Area Network Services In the event of an emergency admission to a Network Facility Provider, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the admission. The Member will be held harmless and will not be financially responsible for payment for admissions which are determined not to be Medically Necessary and Appropriate, except when the Plan provides prior written notice to the Member that any portion of the admission will not be covered. In such case, the Member will assume financial responsibility for such Inpatient charges. b. Out-of-Area Network Services In the event of an emergency admission to a Network Facility Provider located Out- of-Area, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. In addition, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, to confirm the Plan’s determination of Medical Necessity and Appropriateness. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written certification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Network Facility Provider’s charges from the date appearing on the written notification. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise, if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of an emergency admission to an Out-of-Network Provider, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written notification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Out-of- Network Provider’s charges from the date appearing on the written notification. iii) If a Member DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

Certification of Emergency Admissions. When a Member requires an emergency admission to a Hospital, Psychiatric Hospital, Rehabilitation Hospital, Residential Treatment Facility or Substance Abuse Treatment Facility, benefits for Covered Services will be provided subject to the following: a. In-Area Network Services In the event of an emergency admission to a Network Facility Provider, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the admission. The Member will be held harmless and will not be financially responsible for payment for admissions which are determined not to be Medically Necessary and Appropriate, except when the Plan provides prior written notice to the Member that any portion of the admission will not be covered. In such case, the Member will assume financial responsibility for such Inpatient charges. b. Out-of-Area Network Services In the event of an emergency admission to a Network Facility Provider located Out- of-Area, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. In addition, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, to confirm the Plan’s determination of Medical Necessity and Appropriateness. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written certification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Network Facility Provider’s charges from the date appearing on the written notification. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise, if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of an emergency admission to an Out-of-Network Provider, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written notification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Out-of- Network Provider’s charges from the date appearing on the written notification. iii) If a Member DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

Certification of Emergency Admissions. When a Member requires an emergency admission to a Hospital, Psychiatric Hospital, Rehabilitation Hospital, Residential Treatment Facility Hospital or Substance Abuse Treatment Facility, benefits for Covered Services will be provided subject to the following: a. In-Area Network Services In the event of an emergency admission to a Network Facility Provider, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the admission. The Member will be held harmless and will not be financially responsible for payment for admissions which are determined not to be Medically Necessary and Appropriate, except when the Plan provides prior written notice to the Member that any portion of the admission will not be covered. In such case, the Member will assume financial responsibility for such Inpatient charges. b. Out-of-Area Network Services In the event of an emergency admission to a Network Facility Provider located Out- of-Area, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. In addition, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, to confirm the Plan’s determination of Medical Necessity and Appropriateness. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written certification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Network Facility Provider’s charges from the date appearing on the written notification. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise, if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of an emergency admission to an Out-of-Network Provider, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written notification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Out-of- Network Provider’s charges from the date appearing on the written notification. iii) If a Member DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

Certification of Emergency Admissions. When a Member requires an emergency admission to a Hospital, Psychiatric Hospital, Rehabilitation Hospital, Residential Treatment Facility Facility, or Substance Abuse Treatment Facility, benefits for Covered Services will be provided subject to the following: a. In-Area Network Services In the event of an emergency admission to a Network Facility Provider, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the admission. The Member will be held harmless and will not be financially responsible for payment for admissions which are determined not to be Medically Necessary and Appropriate, except when the Plan provides prior written notice to the Member that any portion of the admission will not be covered. In such case, the Member will assume financial responsibility for such Inpatient charges. b. Out-of-Area Network Services In the event of an emergency admission to a Network Facility Provider Provider, located Out- of-Area, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. In addition, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, to confirm the Plan’s determination of Medical Necessity and Appropriateness. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written certification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Network Facility Provider’s charges from the date appearing on the written notification. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise, if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of an emergency admission to an Out-of-Network Provider, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written notification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Out-of- Network Provider’s charges from the date appearing on the written notification. iii) If a Member DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

Certification of Emergency Admissions. When a Member requires an emergency admission to a Hospital, Psychiatric Hospital, Rehabilitation Hospital, Residential Treatment Facility or Substance Abuse Treatment Facility, benefits for Covered Services will be provided subject to the following: a. In-Area Network Services In the event of an emergency admission to a Network Facility Provider, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the admission. The Member will be held harmless and will not be financially responsible for payment for admissions which are determined not to be Medically Necessary and Appropriate, except when the Plan provides prior written notice to the Member that any portion of the admission will not be covered. In such case, the Member will assume financial responsibility for such Inpatient charges. b. Out-of-Area Network Services In the event of an emergency admission to a Network Facility Provider located Out- of-Area, it shall be the responsibility of the Network Facility Provider to contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. In addition, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, to confirm the Plan’s determination of Medical Necessity and Appropriateness. i) . If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. iii) If a Member elects to remain hospitalized after receiving written certification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Network Facility Provider’s charges from the date appearing on the written notification. iiiii) If a Network Facility Provider DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise, if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of an emergency admission to an Out-of-Network Provider, the Member must contact the Plan within forty-eight (48) hours, or as soon as reasonably possible, after such admission to obtain Certification of the emergency admission. i) If Certification for a Medically Necessary and Appropriate emergency admission has been obtained, as required under this Agreement, and the admission has been determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. ii) If a Member elects to remain hospitalized after receiving written notification from the Plan that such level of care is no longer Medically Necessary and Appropriate, the Member will be financially responsible for the full amount of the Out-of- Network Provider’s charges from the date appearing on the written notification. iii) If a Member DOES NOT CONTACT the Plan for Certification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.