Emergency and Post-Stabilization Services Sample Clauses
The Emergency and Post-Stabilization Services clause defines the obligations of parties regarding the provision and coverage of emergency medical care and subsequent stabilization services. It typically requires that emergency services be provided without prior authorization and ensures that patients receive necessary care until they are medically stable, regardless of network status. This clause is essential for guaranteeing immediate access to critical healthcare in emergencies and clarifies payment responsibilities, thereby protecting patients from delays or denials of urgent treatment.
Emergency and Post-Stabilization Services. Emergency Services shall be available to Members twenty-four (24) hours-a- day, seven (7) days-a-week. The CONTRACTOR shall review and approve or disapprove Claims for Emergency Services based on the definition of Emergency Medical Condition specified in Section 2 of this Agreement. The CONTRACTOR shall base coverage decisions for Emergency Services on the severity of symptoms at the time of presentation and shall cover Emergency Services when the presenting symptoms are of sufficient severity to constitute an Emergency Medical Condition in the judgment of a prudent layperson. The CONTRACTOR shall not impose restrictions on the coverage of Emergency Services that are more restrictive than those permitted by the prudent layperson standard. The CONTRACTOR shall have policies that address emergency and non- emergency use of services provided in an outpatient setting. Such policies and procedures shall include, among other things, the role of CSAs in crisis response for Members with SMI/SED, including handling the immediate crisis, crisis stabilization, follow-up after crisis, and crisis prevention. The CONTRACTOR shall provide coverage for inpatient and outpatient Emergency Services, furnished by a qualified provider, regardless of whether the Member obtains the services from a Contract Provider, that are needed to evaluate or stabilize an Emergency Medical Condition that is found to exist using the prudent layperson standard. These services shall be provided without prior authorization in accordance with 42 C.F.R. § 438.114. The CONTRACTOR shall not limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms. Post-Stabilization Services are Covered Services related to an Emergency Medical Condition that are provided after a Member is Stabilized in order to maintain the Stabilized condition or to improve or resolve the Member’s Emergency Medical Condition.
Emergency and Post-Stabilization Services. Hour Coverage The HMO must provide all emergency contract services and post- stabilization services as defined in this Contract 24 hours each day, seven days a week, either by the HMO’s own facilities or through arrangements approved by the Department with other providers. The HMO must:
Emergency and Post-Stabilization Services. In accordance with Section 1852(d)(2) of the Act and 42 C.F.R. §§ 438.114(b), 422.113(c), 438.114(d), and 438.114(e), the Contractor must cover and pay for Emergency and Post-Stabilization Care Services. This includes ensuring the determination of the attending emergency physician, or the Provider actually treating the Dental Health Plan Enrollee, of when the Dental Health Plan Enrollee is sufficiently stabilized for transfer or discharge is binding on the Contractor and State for coverage and payment of Emergency and Post-Stabilization Care Services.
Emergency and Post-Stabilization Services. 4.2.11.1. Emergency Services
4.2.11.1.1. Emergency Services are defined in Appendix A and include but are not limited to:
4.2.11.1.1.1. Radiology, 4.2.11.1.1.2. Pathology, 4.2.11.1.1.3. Emergency Medicine,
Emergency and Post-Stabilization Services. Hour Coverage The PIHP must provide all emergency contract services and post- stabilization services as defined in this contract 24 hours a day, seven days a week, either by the PIHP’s own facilities or through arrangements approved by the Department with other providers. The PIHP must:
Emergency and Post-Stabilization Services