Continuity of Care and Out-of-Network Providers Sample Clauses

Continuity of Care and Out-of-Network Providers. The MCO must ensure that the care of newly enrolled Members is not disrupted or interrupted. The MCO must take special care to provide continuity in the care of newly enrolled Members whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if Medically Necessary Covered Services are disrupted or interrupted. See Section 8.1.14, “Disease Management/Health Home Services.” for specific requirements for new Members transferring to the MCO’s Disease Management/Health Home Service Program.

Continuity of Care and Out-of-Network Providers. 6.4.1 HMO must ensure that the care of newly enrolled Members is not disrupted or interrupted. HMO must take special care to provide continuity in the care of newly enrolled Members whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if care is disrupted or interrupted. 6.4.2 Pregnant Members with 12 weeks or less remaining before the expected delivery date must be allowed to remain under the care of the Member's current OB/GYN through the Member's postpartum checkup even if the provider is out-of-network. If the Member wants to change her OB/GYN to one who is in the plan, she must be allowed to do so if the provider to whom she wishes to transfer agrees to accept her in the last trimester. 6.4.3 HMO must pay a Member's existing out-of-network providers for covered services until the Member's records, clinical information and care can be transferred to a network provider. Payment must be made within the time period required for network providers. HMO may pay any out-of-network provider a reasonable and 36 Dallas Service Area Contract 43 customary amount determined by the HMO. This Article does not extend the obligation of HMO to reimburse existing out-of-network providers of ongoing care for more than 90 days after Member enrolls in HMO or for more than nine months in the case of Member who at the time of enrollment in HMO, have been diagnosed with and receiving treatment for a terminal illness. The obligation of HMO to reimburse the Member's existing out-of-network provider for services provided to a pregnant Member with 12 weeks or less remaining before the expected delivery date extends through delivery of the child, immediate postpartum care, and the follow-up checkup within the first six weeks of delivery. 6.4.4 HMO must provide or pay out-of-network providers who provide covered services to Members who move out of the service area through the end of the period for which capitation has been paid. 6.4.5 HMO must provide assistance to providers requiring PCP verification 24 hours a day 7 days a week. 6.4.5.1 HMO must provide TDH with policies and procedures indicating how the HMO will provide PCP verification as indicated in Article

Continuity of Care and Out-of-Network Providers. The MCO must ensure that the care of newly enrolled Members is not disrupted or interrupted. The MCO must take special care to provide continuity in the care of newly enrolled Members whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if Medically Necessary Covered Services are disrupted or interrupted. See Section 8.1.14, “Disease Management/Health Home Services.” for specific requirements for new Members transferring to the MCO’s Disease Management/Health Home Service Program. The MCO is required to ensure that Expansion Service Area clients receiving acute care services through a prior authorization as of the STAR and STAR+PLUS Operational Start Date receive continued authorization of those services for the shorter of: (1) 90 calendar days after Operational Start Date, or (2) until the expiration date of the prior authorization The MCO is also required to ensure that Expansion Service Area clients receiving Community-based Long Term Care Services as of the STAR+PLUS Operational Start Date receive continued authorization of those services for up to six (6) months after the Operational