Common use of Crisis, Urgent and Emergency Services Clause in Contracts

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-3840. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny and is required to pay for a claim for Emergency Services, regardless of whether the Provider that furnishes the services has a contract with Contractor. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition. (6) Contractor shall cover and pay for Post Stabilization Services, as provided for in OAR 410-141-3840 and 42 CFR § 438.114. Contractor is financially responsible for (7) Contractor’s financial responsibility for Post Stabilization Services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § 438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within Contractor’s network, when Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. 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. Based on this determination, Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department Provider, Hospital, or Fiscal Agent to notify a Member's Primary Care Provider of the Member's screening and treatment within ten (10) days of presentation for Emergency Services, as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of Contractor instructs the Member to seek Emergency Services, consistent with 42 CFR § 438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires Emergency Services.

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition emergency medical condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, Services as provided for in OAR 410-141-3840 3140 and 42 CFR § 438.114. Contractor is financially responsible forfor Post- Stabilization Services obtained within or outside the Provider Network that are pre- approved by a Participating Provider or other Contractor representative as specified in 42 CFR 438.114(c)(1)(ii)(B). Contractor shall limit charges to Members for Post- Stabilization services to an amount no greater than what the Contractor would charge the Member for the services obtained within the Provider Network. (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § 438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. The attending emergency Physicianphysician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge. Based on this determination, the Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department Providerthe emergency room provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider primary care provider of the Member's screening and treatment within ten (10) 10 days of presentation for Emergency Services, Services as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member member to seek Emergency Services, consistent with emergency services. 42 CFR § 438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires Emergency Services.

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, as provided for in OAR 410-141-3840 3140 and 42 CFR § §438.114. Contractor is financially responsible forfor Post- Stabilization Services obtained within or outside the Provider Network that are pre- approved by a Participating Provider or other Contractor representative, as specified in 42 CFR §438.114(c)(1)(ii)(B). Contractor shall limit charges to Members for Post- Stabilization services to an amount no greater than what the Contractor would charge the Member for the services obtained within the Provider Network. (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § §438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. 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. Based on this determination, the Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department the emergency room Provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider of the Member's screening and treatment within ten (10) 10 days of presentation for Emergency Services, as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member to seek Emergency Services, consistent with . 42 CFR § 438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation Transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires 911, in accordance with the Emergency Services prudent layperson standard described in Exhibit A, definitions for “Emergency Services” and “Emergency Medical Condition.”

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 3140 and 42 CFR § §438.114, Contractor shall not deny and is required to deny, but must pay for a claim for Emergency Services, regardless of whether the Provider that furnishes the services has a contract with Contractor. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, as provided for in OAR 410-141-3840 3140 and 42 CFR § §438.114. Contractor is financially responsible for (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § §438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. 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. Based on this determination, the Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department emergency room Provider, Hospital, or Fiscal Agent fiscal agent to notify a Member's Primary Care Provider of the Member's screening and treatment within ten (10) days of presentation for Emergency Services, as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member to seek Emergency Services, consistent with . 42 CFR § 438.114. (12) In accordance with OAR 410000-141000-3945 0000 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires Emergency Services.

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition emergency medical condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, Services as provided for in OAR 410-141-3840 3140 and 42 CFR § 438.114. Contractor is financially responsible forfor Post- Stabilization Services obtained within or outside the Provider Network that are pre- approved by a Participating Provider or other Contractor representative as specified in 42 CFR 438.114(c)(1)(ii)(B). Contractor shall limit charges to Members for Post- Stabilization services to an amount no greater than what the Contractor would charge the Member for the services obtained within the Provider Network. (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § 438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. The attending emergency Physicianphysician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge. Based on this determination, Contractor will be liable for payment.actually (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department Providerthe emergency room provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider primary care provider of the Member's screening and treatment within ten (10) 10 days of presentation for Emergency Services, Services as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member member to seek Emergency Services, consistent with emergency services. 42 CFR § 438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, Members including Ambulance services dispatched through 911 when a Member’s medical condition requires 911, in accordance with the Emergency Services prudent layperson standard described in Exhibit A, definitions for “Emergency Services” and “Emergency Medical Condition.”

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition emergency medical condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, Services as provided for in OAR 410-141-3840 3140 and 42 CFR § 438.114. Contractor is financially responsible forfor Post- Stabilization Services obtained within or outside the Provider Network that are pre- approved by a Participating Provider or other Contractor representative as specified in 42 CFR 438.114(c)(1)(ii)(B). Contractor shall limit charges to members for Post- Stabilization services to an amount no greater than what the Contractor would charge the member for the services obtained within the Provider Network. (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member enrollee is discharged, consistent with the requirements of 42 CFR § . 42CFR 438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Memberenrollee’s stabilized condition without preauthorization, and regardless of whether the Member enrollee obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. The attending emergency Physicianphysician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge. Based on this determination, the Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services services based on any failure of an Emergency Department Providerthe emergency room provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider primary care provider of the Member's screening and treatment within ten (10) 10 calendar days of presentation for Emergency Services, services as specified in 42 CFR § 438.114438.114(d)(1)(ii). (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member member to seek Emergency Services, consistent with 42 CFR § 438.114emergency services. 42CFR438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires Emergency Services.

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition emergency medical condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, Services as provided for in OAR 410-141-3840 3140 and 42 CFR § 438.114. Contractor is financially responsible forfor Post- Stabilization Services obtained within or outside the Provider Network that are pre- approved by a Participating Provider or other Contractor representative as specified in 42 CFR 438.114(c)(1)(ii)(B). Contractor shall limit charges to members for Post- Stabilization services to an amount no greater than what the Contractor would charge the member for the services obtained within the Provider Network. (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member enrollee is discharged, consistent with the requirements of 42 CFR § . 42CFR 438.114. (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Memberenrollee’s stabilized condition without preauthorization, and regardless of whether the Member enrollee obtains the services within the Contractor’s network, when Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour.the (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. The attending emergency Physicianphysician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge. Based on this determination, the Contractor will be liable for payment. (10) Contractor shall not refuse to cover Emergency Services services based on any failure of an Emergency Department Providerthe emergency room provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider primary care provider of the Member's screening and treatment within ten (10) 10 calendar days of presentation for Emergency Services, services as specified in 42 CFR § 438.114438.114(d)(1)(ii). (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member member to seek Emergency Services, consistent with 42 CFR § 438.114emergency services. 42CFR438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, including Ambulance services dispatched through 911 when a Member’s medical condition requires Emergency Services.

Crisis, Urgent and Emergency Services. (1) Contractor may not require Prior Authorization for Emergency Services nor limit what constitutes an Emergency Medical Condition emergency medical condition on the basis of lists of diagnoses or symptoms. (2) Contractor shall provide an after-hours call-in system adequate to triage Triage Urgent Care and Emergency Service calls, consistent with OAR 410-141-38403140. (3) As provided for in OAR 410-141-3840 and 42 CFR § 438.114, Contractor shall not deny cover and is required to pay for a claim for Emergency Services, regardless of whether the Provider provider that furnishes the services has a contract with Contractor, as provided for in OAR 410-141-3140. (4) Contractor is encouraged to establish agreements with Hospitals in its Service Area for the payment of emergency screening exams. (5) Contractor shall not deny payment for treatment obtained when a Member has an Emergency Medical Condition or Emergency Dental Condition, including Behavioral Health, or requires Dental Emergency Services, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition or Emergency Dental Condition. (6) Contractor shall cover and pay for Post Post-Stabilization Services, Services as provided for in OAR 410-141-3840 3140 and 42 CFR § 438.114. Contractor is financially responsible for (7) Contractor’s financial responsibility for Post Stabilization Services post-stabilization care services it has not pre- approved ends when the Member is discharged, consistent with the requirements of 42 CFR § 438.114.not (8) Contractor shall cover Post Stabilization Services administered to maintain, improve, or resolve the Member’s stabilized condition without preauthorization, and regardless of whether the Member obtains the services within the Contractor’s network, when the Contractor could not be contacted for pre-approval or did not respond to a request for pre-approval within one hour. (9) A Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or to stabilize the Member. 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. Based on this determination, Contractor will be liable for payment.to (10) Contractor shall not refuse to cover Emergency Services based on any failure of an Emergency Department Providerthe emergency room provider, Hospitalhospital, or Fiscal Agent to notify a fiscal agent not notifying the Member's Primary Care Provider primary care provider of the Member's screening and treatment within ten (10) 10 days of presentation for Emergency Services, Services as specified in 42 CFR § 438.114. (11) Contractor shall not deny payment for treatment obtained when a representative of the Contractor instructs the Member member to seek Emergency Services, consistent with emergency services. 42 CFR § 438.114. (12) In accordance with OAR 410-141-3945 and 410-120-0000(91) Contractor shall pay for emergency Ambulance transportation for Members, Members including Ambulance services dispatched through 911 when a Member’s medical condition requires 911, in accordance with the Emergency Services prudent layperson standard described in Exhibit A, definitions for “Emergency Services” and “Emergency Medical Condition.”