Emergency Care Requirements Sample Clauses

Emergency Care Requirements. The PSN shall submit to the Agency for review and final determination all denied Appeals from behavioral health care providers and out-of-plan, non-participating Behavioral Health Care Providers for denied Emergency Behavioral Health Service claims. The provider, whether a participating provider or not, must submit the denied Appeal to the Agency within ten (10) days after receiving notice of the PSN's final Appeal determination.

Emergency Care Requirements. The PDHP shall make provisions for and advise all members of the provisions governing emergency use. Emergency-related definitions are in Section 100.0, Glossary, of this contract. Requirements for the PDHP to provide emergency services and care are as follows: a. In providing for emergency services and care as a covered service, the PDHP shall not: 1. Require prior authorization for emergency services and care. 2. Indicate that emergencies are covered only if care is secured within a certain period of time. 3. Use terms such as “life threatening” or “bona fide” to qualify the kind of emergency that is covered. 4. Deny payment based on the member’s failure to notify the PDHP in advance or within a certain period of time after the care is given. b. When a member is present at a hospital seeking emergency services and care, the determination as to whether an emergency dental condition (provided in Section 100.0, Glossary) exists shall be made, for the purpose of treatment, by a dentist or a physician of the hospital or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of the hospital dentist or physician. The dentist or physician or the appropriate personnel shall indicate in the patient’s chart the results of the screening, examination, and evaluation. The PDHP shall compensate the dental provider for any dental services that are incidental to the screening, evaluations, and examination that are reasonably calculated to assist the health care provider in arriving at a determination as to whether the patient’s condition is an emergency dental condition. The PDHP shall compensate the dental provider for emergency dental services and care. If a determination is made that an emergency dental condition does not exist, the PDHP is not responsible for payment for services rendered subsequent to that determination. c. The PDHP shall not deny payment for emergency services and care. d. If the member’s primary care dentist responds to the notification, the hospital-based provider and the primary care dentist may discuss the appropriate care and treatment of the member. Notwithstanding any other state law, a hospital may request and collect insurance or financial information from a patient in accordance with federal law to determine if the patient is a member of the PDHP, if emergency services and care are not delayed. e. As described in Section 409.9128(5), reimbursement for services provided to a member of a PDHP under ...

Emergency Care Requirements. In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the contractor must also cover post-stabilization services without authorization, regardless of whether the enrollee obtains the service within or outside the contractor's network, for the following situations: A. Post-stabilization care services that were pre-approved by the contractor, or were not pre-approved by the contractor because the contractor did not respond to the treating provider's request for pre-approval within one (1) hour after being requested to approve such care, or could not be contacted for pre-approval. B. Post-stabilization services are services subsequent to an emergency that a treating physician views as medically necessary after an emergency medical condition has been stabilized. These are not emergency services, but are non-emergency services that the contractor could choose not to cover out-of-contractor except in the circumstances described above.