Common use of Coverage of Payment of Emergency Services Clause in Contracts

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.

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-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.

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-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.