Common use of Emergency Services - Behavioral Health Services Clause in Contracts

Emergency Services - Behavioral Health Services. The Health Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. a. Crisis Intervention Mental Health Services and Post-Stabilization Care Services (1) Crisis intervention services include intervention activities of less than twenty-four (24) hour duration (within a twenty-four (24) hour period) designed to stabilize an enrollee in a psychiatric emergency. (2) Post-stabilization care services include any of the mandatory services that a treating physician views as medically necessary, that are provided after an enrollee is stabilized from an emergency mental health condition in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition. b. Emergency service providers shall make a reasonable attempt to notify the Health Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the provider shall notify the Health Plan within twenty-four (24) hours of learning the enrollee’s identity. c. The emergency service provider shall notify the Health Plan as soon as possible prior to discharge of the enrollee from the emergency care area or notify the Health Plan within twenty-four (24) hours or on the next business day after the enrollee’s inpatient admission. d. The Health Plan shall process all out-of-plan emergency behavioral health service claims within the time frames specified for emergency claims payment in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services. e. The Health Plan shall submit to BMHC within ten (10) calendar days after the Health Plan’s final appeal determination 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. f. The Health Plan shall not deny emergency services for enrollees presenting at receiving facilities for involuntary examination under the Xxxxx Act. (1) The receiving facility will make every effort to notify the Health Plan within twenty-four (24) hours of receiving the enrollee. (2) The Health Plan shall begin coordinating the enrollee’s care upon notification by the receiving facility. (3) A stabilized condition is determined when the physician treating the enrollee decides when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the Health Plan (42 CFR 438.114(d)(3). g. Fee-for-service Health Plans shall follow provisions of subparagraph f. above for receiving facilities that are not CSUs.

Emergency Services - Behavioral Health Services. The Health Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. a. Crisis Intervention Mental Health Services and Post-Stabilization Care Services (1) Crisis intervention services include intervention activities of less than twenty-four (24) hour duration (within a twenty-four (24) hour period) designed to stabilize an enrollee in a psychiatric emergency. (2) Post-stabilization care services include any of the mandatory services that a treating physician views as medically necessary, that are provided after an enrollee is stabilized from an emergency mental health condition in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition. b. Emergency service providers An out-of-area, non-participating provider shall make a reasonable attempt to notify the Health Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the out-of-area, non-participating provider shall notify the Health Plan within twenty-four (24) hours of learning the enrollee’s identity. The out-of-area, non-participating provider shall deliver to the Health Plan the medical records that document that the identity of the enrollee could not be ascertained at the time the enrollee presented for emergency behavioral health services due to the enrollee’s condition. c. The emergency service If the out-of-area, non-participating provider shall notify fails to provide the Health Plan as soon as possible prior to discharge with an accounting of the enrollee from the emergency care area or notify the Health Plan enrollee’s presence and status within twenty-four (24) hours or on after the next business day after enrollee presents for treatment and provides identification, the Health Plan shall approve claims only for the time period required for treatment of the enrollee’s inpatient admissionemergency behavioral health services, as documented by the enrollee’s medical record. d. The Health Plan shall process review and approve or disapprove all out-of-plan emergency behavioral health service claims within the time frames specified for emergency claims payment in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services. e. The Health Plan shall submit to BMHC within ten (10) calendar days after the Health Plan’s final appeal determination 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 BMHC within ten (10) calendar days after receiving notice of the Health Plan’s final appeal determination. f. The Health Plan shall not deny emergency services for enrollees presenting at participating or non-participating receiving facilities for involuntary examination under HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract the Xxxxx Act. The Health Plan shall evaluate the need for and authorize or deny any additional services within three (3) hours of being notified by telephone from the receiving facility. (1) The receiving facility will make every effort must notify the Health Plan within four (4) hours of the enrollee’s presenting. If the receiving facility fails to notify the Health Plan of the enrollee’s presence and status within twenty-four (244) hours, the Health Plan shall pay for only the first four (4) hours of receiving the enrollee’s treatment, subject to medical necessity. (2) The If the receiving facility is a non-participating receiving facility and documents in the medical record that it is unable, after a good faith effort, to identify the enrollee and, therefore, fails to notify the Health Plan of the enrollee’s presence, the Health Plan shall begin coordinating cover medical stabilization lasting no more than three (3) calendar days from the date the enrollee presented at the receiving facility, as documented by the enrollee’s care upon notification by medical record and subject to medical necessity, unless there is irrefutable evidence in the receiving facility. (3) A stabilized condition is determined when medical record that a longer period was required to treat the physician treating the enrollee decides when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the Health Plan (42 CFR 438.114(d)(3)enrollee. g. Fee-for-service Health Plans shall follow provisions of subparagraph f. above for receiving facilities that are not CSUs.

Emergency Services - Behavioral Health Services. The Health Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. a. Crisis Intervention Mental Health Services and Post-Stabilization Care Services (1) Crisis intervention services include intervention activities of less than twenty-four (24) hour duration (within a twenty-four (24) hour period) designed to stabilize an enrollee in a psychiatric emergency. (2) Post-stabilization care services include any of the mandatory services that a treating physician views as medically necessary, that are provided after an enrollee is stabilized from an emergency mental health condition in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition. b. Emergency service providers An out-of-area, non-participating provider shall make a reasonable attempt to notify the Health Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the out-of-area, non-participating provider shall notify the Health Plan within twenty-four (24) hours of learning the enrollee’s identity. The out-of-area, non-participating provider shall deliver to the Health Plan the medical records that document that the identity of the enrollee could not be ascertained at the time the enrollee presented for emergency behavioral health services due to the enrollee’s condition. c. The emergency service If the out-of-area, non-participating provider shall notify fails to provide the Health Plan as soon as possible prior to discharge with an accounting of the enrollee from the emergency care area or notify the Health Plan enrollee’s presence and status within twenty-four (24) hours or on after the next business day after enrollee presents for treatment and provides identification, the Health Plan shall approve claims only for the time period required for treatment of the enrollee’s inpatient admissionemergency behavioral health services, as documented by the enrollee’s medical record. d. The Health Plan shall process review and approve or disapprove all out-of-plan emergency behavioral health service claims within the time frames specified for emergency claims payment in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services. e. The Health Plan shall submit to BMHC within ten (10) calendar days after the Health Plan’s final appeal determination 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 BMHC within ten (10) calendar days after receiving notice of the Health Plan’s final appeal determination. f. The Health Plan shall not deny emergency services for enrollees presenting at participating or non-participating receiving facilities for involuntary examination under WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract the Xxxxx Act. The Health Plan shall evaluate the need for and authorize or deny any additional services within three (3) hours of being notified by telephone from the receiving facility. (1) The receiving facility will make every effort must notify the Health Plan within four (4) hours of the enrollee’s presenting. If the receiving facility fails to notify the Health Plan of the enrollee’s presence and status within twenty-four (244) hours, the Health Plan shall pay for only the first four (4) hours of receiving the enrollee’s treatment, subject to medical necessity. (2) The If the receiving facility is a non-participating receiving facility and documents in the medical record that it is unable, after a good faith effort, to identify the enrollee and, therefore, fails to notify the Health Plan of the enrollee’s presence, the Health Plan shall begin coordinating cover medical stabilization lasting no more than three (3) calendar days from the date the enrollee presented at the receiving facility, as documented by the enrollee’s care upon notification by medical record and subject to medical necessity, unless there is irrefutable evidence in the receiving facility. (3) A stabilized condition is determined when medical record that a longer period was required to treat the physician treating the enrollee decides when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the Health Plan (42 CFR 438.114(d)(3)enrollee. g. Fee-for-service Health Plans shall follow provisions of subparagraph f. above for receiving facilities that are not CSUs.

Emergency Services - Behavioral Health Services. The Health Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. a. Crisis Intervention Mental Health Services and Post-Stabilization Care Services (1) Crisis intervention services include intervention activities of less than twenty-four (24) hour duration (within a twenty-four (24) hour period) designed to stabilize an enrollee in a psychiatric emergency. (2) Post-stabilization care services include any of the mandatory services that a treating physician views as medically necessary, that are provided after an enrollee is stabilized from an emergency mental health condition in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition. b. Emergency service providers shall make a reasonable attempt to notify the Health Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the provider shall notify the Health Plan within twenty-four (24) hours of learning the enrollee’s identity. c. The emergency service provider shall notify the Health Plan as soon as possible prior to discharge of the enrollee from the emergency care area or notify the Health Plan within twenty-four (24) hours or on the next business day after the enrollee’s inpatient admission. d. The Health Plan shall process all out-of-plan emergency behavioral health service claims within the time frames specified for emergency claims payment in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services. e. The Health Plan shall submit to BMHC within ten (10) calendar days after the Health Plan’s final appeal determination 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. f. The Health Plan shall not deny emergency services for enrollees presenting at receiving facilities for involuntary examination under the Xxxxx Bxxxx Act. (1) The receiving facility will make every effort to notify the Health Plan within twenty-four (24) hours of receiving the enrollee. (2) The Health Plan shall begin coordinating the enrollee’s care upon notification by the receiving facility. (3) A stabilized condition is determined when the physician treating the enrollee decides when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the Health Plan (42 CFR 438.114(d)(3). g. Fee-for-service Health Plans shall follow provisions of subparagraph f. above for receiving facilities that are not CSUs. 33. Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item D., Transition Plan, sub-item 2., the second sentence is hereby amended to now read as follows: For enrollees who have received behavioral health services for at least six (6) months from a behavioral health care provider, whether the provider is in the Health Plan’s network or not, the Health Plan shall continue to authorize all valid claims until the Health Plan has: Unless otherwise stated, this amendment is effective upon execution. All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the Contract. This amendment, and all its attachments, are hereby made part of the Contract. This amendment cannot be executed unless all previous amendments to this Contract have been fully executed.

Emergency Services - Behavioral Health Services. The Health Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. a. Crisis Intervention Mental Health Services and Post-Stabilization Care Services (1) Crisis intervention services include intervention activities of less than twenty-four (24) hour duration (within a twenty-four (24) hour period) designed to stabilize an enrollee in a psychiatric emergency. (2) Post-stabilization care services include any of the mandatory services that a treating physician views as medically necessary, that are provided after an enrollee is stabilized from an emergency mental health condition in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition. b. Emergency service providers An out-of-area, non-participating provider shall make a reasonable attempt to notify the Health Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the out-of-area, nonparticipating provider shall notify the Health Plan within twenty-four (24) hours of learning the enrollee’s identity. The out-of-area, non-participating provider shall deliver to the Health Plan the medical records that document that the identity of the enrollee could not be ascertained at the time the enrollee presented for emergency behavioral health services due to the enrollee’s condition. c. The emergency service If the out-of-area, non-participating provider shall notify fails to provide the Health Plan as soon as possible prior to discharge with an accounting of the enrollee from the emergency care area or notify the Health Plan enrollee’s presence and status within twenty-four (24) hours or on after the next business day after enrollee presents for treatment and provides identification, the Health Plan shall approve claims only for the time period required for treatment of the enrollee’s inpatient admissionemergency behavioral health services, as documented by the enrollee’s medical record. d. The Health Plan shall process review and approve or disapprove all out-of-plan emergency behavioral health service claims within the time frames specified for emergency claims payment in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services. e. The Health Plan shall submit to BMHC within ten (10) calendar days after the Health Plan’s final appeal determination 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 BMHC within ten (10) calendar days after receiving notice of the Health Plan’s final appeal determination. f. The Health Plan shall not deny emergency services for enrollees presenting at participating or non-participating receiving facilities for involuntary examination under the Xxxxx Act. The Health Plan shall evaluate the need for and authorize or deny any additional services within three (3) hours of being notified by telephone from the receiving facility. (1) The receiving facility will make every effort must notify the Health Plan within four (4) hours of the enrollee’s presenting. If the receiving facility fails to notify the Health Plan of the AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract enrollee’s presence and status within twenty-four (244) hours, the Health Plan shall pay for only the first four (4) hours of receiving the enrollee’s treatment, subject to medical necessity. (2) The If the receiving facility is a non-participating receiving facility and documents in the medical record that it is unable, after a good faith effort, to identify the enrollee and, therefore, fails to notify the Health Plan of the enrollee’s presence, the Health Plan shall begin coordinating cover medical stabilization lasting no more than three (3) calendar days from the date the enrollee presented at the receiving facility, as documented by the enrollee’s care upon notification by medical record and subject to medical necessity, unless there is irrefutable evidence in the receiving facility. (3) A stabilized condition is determined when medical record that a longer period was required to treat the physician treating the enrollee decides when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the Health Plan (42 CFR 438.114(d)(3)enrollee. g. Fee-for-service Health Plans shall follow provisions of subparagraph f. above for receiving facilities that are not CSUs.