Other Contractor-Liable Post-Stabilization Care Services. (A) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside the Contractor’s network that are not pre-approved by a Contractor representative, but are administered to maintain the Enrollee’s stabilized condition within one hour of a request to the Contractor for pre-approval of further Post-Stabilization Care Services.
(B) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside of the Contractor’s network that are not pre-approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s stabilized condition if:
(1) The Contractor does not respond to a request for pre-approval within one hour of the request;
(2) The Contractor cannot be contacted; or
(3) The Contractor representative and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Contractor physician is not available for consultation. In this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with the care of the Enrollee until a Contractor physician is reached, or one of the following criteria, found in 42 CFR 422.113(c)(3) is met:
(i) A Contractor physician with privileges at the treating hospital assumes responsibility for the Enrollee’s care;
(ii) A Contractor physician resumes responsibility for the Enrollee’s care;
(iii) A Contractor representative and the treating physician reach an agreement concerning the Enrollee’s care; or
(iv) The Enrollee is discharged.
Other Contractor-Liable Post-Stabilization Care Services. (A) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside the Contractor’s network that are not pre-approved by a Contractor representative, but are administered to maintain the Enrollee’s stabilized condition within one hour of a request to the Contractor for pre-approval of further Post-Stabilization Care Services.
(B) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside of the Contractor’s network that are not pre-approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s stabilized condition if:
(1) The Contractor does not respond to a request for pre-approval within one hour of the request;
(2) The Contractor cannot be contacted; or
(3) The Contractor representative and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Contractor physician is not available for consultation. In this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with the care of the Enrollee until a Contractor physician is reached, or one of the following criteria, found in 42 CFR 422.113(c)(3) is met:
Other Contractor-Liable Post-Stabilization Care Services. (A) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside the Contractor’s network that are not pre-approved by a Contractor representative, but are administered to maintain the Enrollee’s stabilized condition within one hour of a request to the Contractor for pre-approval of further Post-Stabilization Care Services.
(B) The Contractor is financially responsible for Post-Stabilization Care Services obtained within or outside of the Contractor’s network that are not pre-approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s stabilized condition if:
