Coverage of Payment of Emergency Services Sample Clauses

Coverage of Payment of Emergency Services. The HMO must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The HMO may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the member’s primary care provider, or HMO of the member’s screening and treatment within ten (10) days of presentation for emergency services. The HMO in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO as identified in 42 CFR § 438.114(b) and 42 CFR § 438.114(d) as responsible for coverage and payment. Nothing in this requirement mandates the HMO to reimburse for non-authorized post-stabilization services. 1) The HMO shall provide emergency services consistent with 42 CFR § 438.114. It is financially responsible for emergency services whether obtained within or outside the HMO’s network. This includes paying for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 2) The HMO may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. 3) The HMO may not deny payment for emergency services for a member with an emergency medical condition (even if the absence of immediate medical attention would not have had the outcomes specified in paragraphs 1., 2. and 3. of part a. of the definition of Emergency Medical Condition) or for a member who had HMO approval to seek emergency services. 4) The member may not be held liable for payment of screening and treatment needed to diagnose the specific condition or stabilize the patient. 5) The treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO.
Sample 1Sample 2Sample 3See All (7)
AutoNDA by SimpleDocs
Coverage of Payment of Emergency Services. The PIHP must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The PIHP may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the member’s primary care provider, or PIHP of the member’s screening and treatment within ten (10) days of presentation for emergency services. The PIHP in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the PIHP as identified in 42 CFR 438.114(b) and 42 CFR 438.114(d) as responsible for coverage and payment. Nothing in this requirement mandates the PIHP to reimburse for non- authorized post-stabilization services. 1) The PIHP shall provide emergency services consistent with 42 CFR 2) The PIHP may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. 3) The PIHP may not deny payment for emergency services for a member with an emergency medical condition (even if the absence of immediate medical attention would not have had the outcomes specified in paragraphs 1., 2. and 3. of part a. of the definition of Emergency Medical Condition) or for a member who had PIHP approval to seek emergency services. 4) The member may not be held liable for payment of screening and treatment needed to diagnose the specific condition or stabilize the patient. 5) The treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the PIHP.
Sample 1Sample 2Sample 3See All (6)
Coverage of Payment of Emergency Services. The PIHP must promptly provide or pay for needed contract services for mental health emergency and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The PIHP may not refuse to cover mental health emergency services based on the provider, hospital, or fiscal agent not notifying the member’s primary care provider, or PIHP of the member’s screening and treatment within ten (10) days of presentation for emergency mental health services. The PIHP in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the PIHP as identified in 42 CFR § 438.114(b) and 42 CFR § 438.114(d) as responsible for coverage and payment. Nothing in this requirement mandates the PIHP to reimburse for non-authorized post-stabilization services. a. The PIHP shall provide emergency mental health services consistent with 42 CFR § 438.114. It is financially responsible for emergency services whether obtained within or outside the PIHP’s network. This includes paying for an appropriate screening examination to determine whether or not a mental health emergency exists. b. The PIHP may not limit what constitutes an emergency mental health condition on the basis of lists of diagnoses or symptoms. c. The PIHP may not deny payment for emergency services for a member with an emergency mental health condition (even if the absence of immediate attention would not have had the outcomes specified in paragraphs 3 and 4 of the definition of Emergency Medical Condition) or for a member who had PIHP approval to seek emergency services. d. The member may not be held liable for payment of screening and treatment needed to diagnose or stabilize the patient. e. The treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the PIHP.
Sample 1
Coverage of Payment of Emergency Services. The HMO must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The HMO may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the member’s primary care provider, or HMO of the member’s screening and treatment within ten (10) days of presentation for emergency services. The HMO in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO as identified in 42 CFR 438.114(b) as responsible for coverage and payment. Nothing in this requirement mandates the HMO to reimburse for non-authorized post-stabilization services. 1) The HMO shall provide emergency services consistent with 42 CFR 438.114. It is financially responsible for emergency services whether obtained within or outside the HMO’s network. This includes paying for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 2) The HMO may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. 3) The HMO may not deny payment for emergency services for a member with an emergency medical condition (even if the absence of immediate medical attention would not have had the outcomes specified in paragraphs 1., 2. and 3. of part a. of the definition of Emergency Medical Condition) or for a member who had HMO approval to seek emergency services. 4) The member may not be held liable for payment of screening and treatment needed to diagnose the specific condition or stabilize the patient. 5) The treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the HMO.
Sample 1
Coverage of Payment of Emergency Services. The County PIHP must promptly provide or pay for needed contract services for mental health emergency and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the entity. The County PIHP may not refuse to cover mental health emergency services based on the provider, hospital, or fiscal agent not notifying the member’s primary care provider, or County PIHP of the member’s screening and treatment within ten (10) days of presentation for emergency mental health services. The County PIHP in coordination with the attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the County PIHP as identified in 42 CFR § 438.114(b) and 42 CFR § 438.114(d) as responsible for coverage and payment. Nothing in this requirement mandates the PIHP to reimburse for non-authorized post-stabilization services. a. The County PIHP provide emergency mental health services consistent with 42 CFR § 438.114. It is financially responsible for emergency services whether obtained within or outside the County PIHP’s network. This includes paying for an appropriate screening examination to determine whether or not a mental health emergency exists. b. Emergency service encounters must be submitted with a primary diagnosis code indicating a behavioral health diagnosis. All other ailments and related services (e.g., x- rays for a broken arm) will be covered by the member’s medical insurance. i. In-Scope Services include, but not limited to: i. Presenting at the Emergency Department in a mental health crisis; ii. Emergency screening for behavioral health services; iii. Admission to inpatient setting for mental health reasons ii. Out-of-Scope Services include, but are not limited to: i. Medical treatment required simultaneously during an Emergency screening for behavioral health services; ii. Any services that are listed as carved out (e.g., pharmacy; see Article IV for complete list); iii. Any services that should be covered by the member’s FFS Medicaid required during an Emergency visit, even if the primary diagnosis code for the overall visit is for a behavioral health diagnosis. c. The County PIHP may not deny payment for emergency behavioral health services for a member with an emergency mental health condition or for a member who had County PIHP approval to seek emergency service...
Sample 1
Coverage of Payment of Emergency Services. The HMO must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services, regardless of whether the provider that furnishes the service has a contract with the
Sample 1

Related to Coverage of Payment of Emergency Services

  • Emergency Services Leave (a) An Employee who engages in a voluntary emergency management activity is entitled to be absent without loss of pay from his or her employment for a total of 5 days per annum commencing at the start of each calendar year. For the avoidance of doubt, any days not utilised by the Employee by the end of the calendar year, do not carry over into the subsequent year. (b) Voluntary emergency management activity has the meaning provided by the FWA.

  • Developer Compensation for Emergency Services If, during an Emergency State, the Developer provides services at the request or direction of the NYISO or Connecting Transmission Owner, the Developer will be compensated for such services in accordance with the NYISO Services Tariff.

  • EMERGENCY SERVICE If you are unable to reach Administrator at 877.634.0964 and you require emergency repair, you may contact any manufacturer authorized service repair facility listed in Your phone book or online. Mail Administrator Your original repair bill along with the technician’s report and a copy of the Agreement to the address at the top of this Agreement for reimbursement. All coverage and exclusions in this Agreement will apply.

  • Emergency Services The parties recognize that in the event of a strike or lockout, situations may arise of an emergency nature. To this end, the Employer and the Union will agree to provide services of an emergency nature.

  • Emergency Service Leave Where employees' services are required for emergency operations by request from Provincial Emergency Programs or appropriate police authority, leave from work as required may be granted without loss of basic pay. If any remuneration, other than for expenses, is received, it shall be remitted to the Employer.

  • Emergency Room Services This plan covers services received in a hospital emergency room when needed to stabilize or initiate treatment in an emergency. If your condition needs immediate or urgent, but non-emergency care, contact your PCP or use an urgent care center. This plan covers bandages, crutches, canes, collars, and other supplies incidental to your treatment in the emergency room as part of our allowance for the emergency room services. Additional services provided in the emergency room such as radiology or physician consultations are covered separately from emergency room services and may require additional copayments. The amount you pay is based on the type of service being rendered. Follow-up care services, such as suture removal, fracture care or wound care, received at the emergency room will require an additional emergency room copayment. Follow- up care services can be obtained from your primary care provider or a specialist. See Dental Services in Section 3 for information regarding emergency dental care services.

  • CONDITIONS FOR EMERGENCY/HURRICANE OR DISASTER - TERM CONTRACTS It is hereby made a part of this Invitation for Bids that before, during and after a public emergency, disaster, hurricane, flood, or other acts of God that Orange County shall require a “first priority” basis for goods and services. It is vital and imperative that the majority of citizens are protected from any emergency situation which threatens public health and safety, as determined by the County. Contractor agrees to rent/sell/lease all goods and services to the County or other governmental entities as opposed to a private citizen, on a first priority basis. The County expects to pay contractual prices for all goods or services required during an emergency situation. Contractor shall furnish a twenty-four (24) hour phone number in the event of such an emergency.

  • ’ Compensation Insurance and Disability Benefits Requirements New York State Workers’ Compensation Law (WCL) §57 & §220 requires the heads of all municipal and state entities to ensure that businesses applying for permits, licenses or contracts, document that they have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals, whether the governmental agency is having the work done or is simply issuing the permit, license or contract. Failure to provide proof of such coverage or a legal exemption will result in a rejection of a Vendor Submission or renewal. A Vendor may not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. 1. Proof of Compliance with Workers’ Compensation Coverage Requirements: An XXXXX form (certificate of insurance) is NOT acceptable proof of workers’ compensation coverage. In order to provide proof of compliance with the requirements of the Workers’ Compensation Law pertaining to workers’ compensation coverage, a Vendor/Contractor shall: a) Be legally exempt from obtaining Workers’ Compensation insurance coverage; or b) Obtain such coverage from an insurance carrier; or c) Be a Workers’ Compensation Board-approved self-insured employer or participate in an authorized self-insurance plan. A Vendor seeking to enter into a Contract with the State of New York shall provide one of the following forms to OGS at the time of Vendor Submission, and thereafter, within three (3) days of request: a) Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxx.xxx.xx.xxx); (Reference applicable Solicitation and Group #s on the form.); b) Certificate of Workers’ Compensation Insurance: i) Form C-105.2 (9/07) if coverage is provided by the Vendor/Contractor’s insurance carrier, the Vendor/Contractor must request that its insurance carrier send this form to OGS, or ii) Form U-26.3 if coverage is provided by the State Insurance Fund, the Vendor/Contractor must request that the State Insurance Fund send this form to OGS; c) Form SI-12, Certificate of Workers’ Compensation Self-Insurance available from the New York State Workers’ Compensation Board’s Self-Insurance Office; or d) Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance available from the Vendor/Contractor’s Group Self-Insurance Administrator.

  • Medical Care and Emergency Leave An employee is entitled to a leave of absence without pay because of any of the following: 1. A personal illness, injury or medical emergency. 2. The death, illness, injury or medical emergency of an individual described in this Article. 3. An urgent matter that concerns an individual described in this Article. For the purposes of this Article, the individuals referred to in this Article are: - the employee’s spouse - a parent, step-parent or xxxxxx parent of the employee or the employee’s spouse - a child, step-child or xxxxxx child of the employee or the employee’s spouse - a grandparent, step-grandparent, grandchild or step-grandchild of the employee or of the employee’s spouse - the spouse of a child of the employee - the employee’s brother or sister - a relative of the employee who is dependent on the employee for care or assistance. An employee who wishes to take leave under this section shall advise his or her Hospital that he or she will be doing so. If the employee must begin the leave before advising the Hospital, the employee shall advise the Hospital of the leave as soon as possible after beginning it. An employee is entitled to take a total of 10 days’ leave under this section each year. If an employee takes any part of a day as leave under this section, the Hospital may deem the employee to have taken one day’s leave on that day for the purposes of this Article. The Hospital may require an employee who takes leave under this section to provide evidence reasonable in the circumstances that the employee is entitled to the leave. Upon the conclusion of an employee’s leave under this Article, the Hospital shall reinstate the employee to the position the employee most recently held with the Hospital, if it still exists, or to a comparable position, if it does not.

  • Emergency Care If you need emergency care, call 911 or go to the nearest hospital emergency room. If you are traveling outside our service area and need urgent care, call the Customer Service number provided in the chart above or visit our website and use the “Find A Doctor” feature to find a BlueCard provider.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!