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

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.

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- non-authorized post-stabilization services.

Coverage of Payment of Emergency Services. The PIHP must promptly provide or pay for needed contract services for mental health 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 mental health 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 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- non-authorized post-stabilization services.