Post-Stabilization Care. The MCO must cover and pay for post-stabilization care services in the amount, duration, and scope necessary to comply with 42 CFR 438.114 and 42 CFR 422.113(c). These regulations state that the MCO must make timely and reasonable payment to or on behalf of the plan enrollee for the following services obtained from a provider or supplier whether or not that provider or supplier contracts with the MCO to provide services covered by the MCO. Post-stabilization care services are covered services that: • Were pre-approved by the organization; or • Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services’ request for pre-approval within one hour after being requested to approve such care, or could not be contacted for pre-approval. Post-stabilization services are not “emergency services,” which the MCO is obligated to cover in-or-out of plan according to the “prudent layperson” standard. Rather, they are non-emergency services that the MCO could choose not to cover out-of-plan except in the circumstances described above. The intent of this provision is to promote efficient and timely coordination of appropriate care of a managed care enrollee after the enrollee’s condition has been determined to be stable.
Post-Stabilization Care. The MCO must cover and pay for post-stabilization care services in the amount, duration, and scope necessary to comply with 42 CFR §438.114 and 42 CFR §422.113(c). These regulations state that the MCO must make timely and reasonable payment to or on behalf of the plan enrollee for the following services obtained from a provider or supplier whether or not that provider or supplier contracts with the MCO to provide services covered by the MCO. Post-stabilization care services are covered services the MCO is financially responsible for if they: • Were pre-approved by the organization; • Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services request for pre-approval within one (1) hour after being requested to approve such care or could not be contacted for pre- approval; • Were obtained within or outside the organization that are not pre-approved by a plan provider or other managed care organization representative, but administered to maintain, improve, or resolve the enrollee's stabilized condition if: o The organization does not respond to a request for pre-approval within one (1) hour; o The organization cannot be contacted; or o The organization representative and the treating physician cannot reach an agreement concerning the enrollee's care and a plan physician is not available for consultation. In this situation, the managed care organization must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with care of the patient until a plan physician is reached or one of the criteria in §422.113(c)(3) is met. Post-stabilization services are not “emergency services,” which the MCO is obligated to cover in-or-out of plan according to the “prudent layperson” standard. Rather, they are non-emergency services that the MCO could choose not to cover out-of-plan except in the circumstances described above. The intent of this provision is to promote efficient and timely coordination of appropriate care of a managed care enrollee after the enrollee’s condition has been determined to be stable. The MCO is required to limit charges to enrollees for post-stabilization care services to an amount no greater than what the MCO would charge the enrollee if he or she obtained the services throught he MCO. The MCO’s financial responsibility for post-stabilization care services it has not pre-approved ends when: • A MCO physician with ...
Post-Stabilization Care. (See Section XI for a definition of Post Stabilization care and conditions that apply)
Post-Stabilization Care. Post Stabilization care means services provided subsequent to an emergency that a treating provider views as medically necessary after an emergency medical condition has been stabilized. They are not emergency services, which Mercy LIFE are obligated to pay. They are non-emergency services that must be pre-approved by Mercy LIFE unless Mercy LIFE did not respond to a request for approval within one hour after being contacted or cannot be contacted for approval in which case the service is considered approved.
Post-Stabilization Care. The term Post-Stabilization Care refers to care that is medically necessary to ensure that the Member remains stable from the time a non-Kaiser Permanente practitioner or facility requests authorization from Kaiser Permanente until:
