Emergency Services and Post-Stabilization Care Services Sample Clauses

Emergency Services and Post-Stabilization Care Services. A. The Contractor is not required under this contract to authorize, refer or provide emergency services or treatment of members who present at hospital emergency rooms. The emergency room is intended for evaluation and treatment of medically necessary emergency conditions. It is not appropriate for providers to refer patients to the emergency room for non-emergency conditions. Medical care for non-emergency medical conditions shall be provided in the office setting. In order to encourage appropriate continuity of care, Contractors shall advise members of the proper use of the emergency room. The OHCA will monitor emergency room services for appropriate use by members and Contractors. B. The Contractor shall not require members to seek prior authorization for services in a medical emergency. Nothing in this paragraph shall limit the Contractor’s provision of these services to an enrolled member consistent with his/her legal scope of practice services to the member in an emergency room setting. C. In the event the Contractor provides emergency care in an emergency room setting to an enrolled member consistent with the Contractor’s legal scope of practice, the OHCA shall reimburse the Contractor the schedule rates set by the OHCA for medically appropriate services. D. The Contractor may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. E. The Contractor may not hold the member liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient. F. In the event the Contractor provides emergency care in an emergency room, the Contractor is responsible for determining when the enrollee is sufficiently stabilized for transfer or discharge.

Emergency Services and Post-Stabilization Care Services. This Section only applies to Providers who are at risk for non-contracted emergency services. A. Emergency Services 1. Subject to 42 CFR section 422.113(b), Blue Shield is responsible for coverage and payment of Emergency Services and must cover and pay for Emergency Services regardless of whether the Provider that furnishes the services has a contract with Blue Shield. Blue Shield may not deny payment for treatment obtained when a Member had an Emergency Medical Condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in 42 CFR section 438.114(a) of the definition of Emergency Medical Condition. Further, Blue Shield may not deny payment for treatment obtained when a representative of Blue Shield instructs the Member to seek Emergency Services. Emergency Services must not be subject to prior authorization by Blue Shield. 2. Blue Shield may not limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms or refuse to reimburse Emergency Services based on the emergency room Provider, hospital, or fiscal agent not notifying the Member’s primary care providers, Blue Shield, or DHCS of the Member’s screening and treatment for Emergency Services. A Member who has an Emergency Medical Condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the Member. 3. Blue Shield must reimburse Providers for Emergency Services received by a Member from Out-of-Network Providers. Payments to non-contracting Providers must be for the treatment of the Emergency Medical Condition, including Medically Necessary inpatient services rendered to a Member until the Member's condition has stabilized sufficiently to permit referral and transfer in accordance with instructions from Blue Shield or Provider or the Member is stabilized sufficiently to permit discharge. The attending emergency Physician or the Provider treating the Member is responsible for determining when the Member is sufficiently stabilized for transfer or discharge and that determination is binding on Blue Shield. Emergency services must not be subject to Prior Authorization by Blue Shield. 4. At a minimum, Blue Shield must reimburse the non-contracting emergency department and, if applicable, its affiliated providers for physician services at the lowest level of the emergency department evaluation and management physician's Current Procedu...

Emergency Services and Post-Stabilization Care Services of the Medi- Cal Contract. (Medi-Cal Contract, Exhibit A, Attachment III, Section 3.1.6.B.9.)