Common use of Emergency and Post-Stabilization Services Clause in Contracts

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.