Coverage and Treatment Sample Clauses
The Coverage and Treatment clause defines the scope of benefits and medical services that an insurance policy or healthcare plan will provide to its members. It typically outlines which types of treatments, procedures, and medications are included or excluded, and may specify requirements such as pre-authorization or network provider usage. This clause ensures that both the insurer and the insured have a clear understanding of what is covered, helping to prevent disputes and manage expectations regarding healthcare costs and access.
Coverage and Treatment of Post-Stabilization Care Services
1) The PIHP is financially responsible for:
i. Emergency and post-stabilization services obtained within or outside the PIHP’s network that are pre-approved by the PIHP. The PIHP is financially responsible for post-stabilization care services consistent with the provision of 42 CFR 422.113(c).
ii. Post-stabilization services obtained within or outside the PIHP’s network that are not pre-approved by the PIHP, but administered to maintain, improve or resolve the member’s stabilized condition if: o The PIHP does not respond to a request for pre-approval of further post-stabilization care services within one (1) hour; o The PIHP cannot be contacted; or o The PIHP and the treating physician cannot reach an agreement concerning the member’s care and a network physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with the PIHP care team or medical director. The treating physician may continue with care of the member until the PIHP care team or medical director is reached or one of the following occurs: ▪ A network physician assumes responsibility for the member’s care at the treating hospital or through transfer; ▪ The treating physician and PIHP reach agreement; or, ▪ The member is discharged.
2) The PIHP’s financial responsibility for post-stabilization care services it did not pre-approve ends when a network provider assumes responsibility for care, at the treating hospital or through transfer, when the treating physician and PIHP reach agreement or when the member is discharged.
Coverage and Treatment of Post-Stabilization Care Services
1) The HMO is financially responsible for:
a) Emergency and post-stabilization services obtained within or outside the HMO’s network that are pre-approved by the HMO. The HMO is financially responsible for post- stabilization care services consistent with the provision of 42 CFR § 438.114(C).
b) Post-stabilization services obtained within or outside the HMO’s network that are not pre-approved by the HMO, but administered to maintain, improve or resolve the member’s stabilized condition if:
1. The HMO does not respond to a request for pre- approval of further post-stabilization care services within one (1) hour;
2. The HMO cannot be contacted; or
3. The HMO and the treating physician cannot reach an agreement concerning the member’s care and a network physician is not available for consultation. In this situation, the HMO must give the treating physician the opportunity to consult with the HMO care team or medical director. The treating physician may continue with care of the member until the HMO care team or medical director is reached or one of the following occurs:
a. A network physician assumes responsibility for the member’s care at the treating hospital or through transfer;
b. The treating physician and HMO reach agreement; or,
c. The member is discharged.
2) The HMO’s financial responsibility for post-stabilization care services it did not pre-approve ends when a network provider assumes responsibility for care, at the treating hospital or through transfer, when the treating physician and HMO reach agreement or when the member is discharged.
3) The HMO must limit charges to members for post-stabilization care services to an amount no greater than what the organization would charge the member if he/she had obtained the services through the HMO. A member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.
Coverage and Treatment of Post-Stabilization Care Services
1) The HMO is financially responsible for: • Emergency and post-stabilization services obtained within or outside the HMO’s network that are pre- approved by the HMO. The HMO is financially responsible for post-stabilization care services consistent with the provision of 42 CFR 438.114(C). • Post-stabilization services obtained within or outside the HMO’s network that are not pre- approved by the HMO, but administered to maintain, improve or resolve the member’s stabilized condition if: o The HMO does not respond to a request for pre-approval of further post-stabilization care services within one (1) hour; o The HMO cannot be contacted; or o The HMO and the treating physician cannot reach an agreement concerning the member’s care and a network physician is not available for consultation. In this situation, the HMO must give the treating physician the opportunity to consult with the HMO care team or medical director. The treating physician may continue with care of the member until the HMO care team or medical director is reached or one of the following occurs:
Coverage and Treatment of Post-Stabilization Care Services
1) The PIHP is financially responsible for: Emergency and post-stabilization services obtained within or outside the PIHP’s network that are pre-approved by the PIHP. The PIHP is financially responsible for post-stabilization care services consistent with the provision of 42 CFR 422.113(c). Post-stabilization services obtained within or outside the PIHP’s network that are not pre-approved by the PIHP, but administered to maintain, improve or resolve the member’s stabilized condition if: o The PIHP does not respond to a request for pre-approval of further post-stabilization care services within one (1) hour; o The PIHP cannot be contacted; or o The PIHP and the treating physician cannot reach an agreement concerning the member’s care and a network physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with the PIHP care team or medical director. The treating physician may continue with care of the member until the PIHP care team or medical director is reached or one of the following occurs: