Post-Stabilization Care Services Clause Samples

Post-Stabilization Care Services. Services related to an emergency medical condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or are provided, to improve or resolve the condition.

Post-Stabilization Care Services. Covered Services related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the condition, or to improve or resolve the Enrollee's condition pursuant to 42 CFR 422.113. Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid Recipient who is subject to Mandatory Assignment or may voluntarily elect to enroll in a given Health Plan, but is not yet an Enrollee of a specific Health Plan. Pre-Enrollment — The provision of Marketing and educational materials to a Medicaid Recipient and assistance in completing the Request for Benefit Information (RBI).

Post-Stabilization Care Services. “Post-stabilization care services” means covered services, related to an emergency medical condition, that are provided after an enrollee is stabilized 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. Post- stabilization of care is covered on both an inpatient and outpatient basis. Post-stabilization care services provided on an inpatient hospital basis are paid for by DVHA for all enrollees in the public insurance programs under the Global Commitment to Health Demonstration. DVHA may conduct concurrent review for post-stabilization services as soon as medically appropriate. However, DVHA must pay for all inpatient post-stabilization care services that are pre-approved by DVHA, all post-stabilization services that are not pre-approved but are administered to maintain the enrollee’s stabilized condition within one hour of a request to DVHA for pre-approval, and all services that are not pre-approved but are administered to maintain, improve or resolve an enrollee’s stabilized condition if the: DVHA does not respond to a request for pre-approval within one hour; DVHA cannot be contacted; or • DVHA’s representative and the treating physician cannot agree concerning the enrollee’s treatment and DVHA does not have a physician available for consultation. In this situation, DVHA must allow the treating physician to continue with care of the enrollee until DVHA physician is reached or the enrollee is discharged. DVHA’s financial responsibility for post-stabilization services for services it has not pre-approved ends when any of the following conditions is met the: • DVHA-contracted physician who has privileges at the treating hospital assumes responsibility for the enrollee’s care; • DVHA-contracted physician assumes responsibility for the enrollee’s care through transfer; • DVHA and the treating physician reach an agreement concerning the enrollee’s care; or Enrollee is discharged. DVHA shall limit charges to enrollees for post-stabilization care services to an amount no greater than what DVHA would charge the enrollee if the enrollee had obtained the services through DVHA.

Post-Stabilization Care Services. Post-Stabilization Care Services will be provided to members in accordance with the definition set forth in Section 1.90 members have the right to receive Post-Stabilization Care Services after they have been stabilized following an admission for an emergency medical condition; provided, however, that the provider of Post-Stabilization Care Services must request prior authorization for those services in accordance with the provisions of this Agreement and the Contractor. The Contractor must pay for Post-Stabilization Care Services if: (1) the Contractor pre-approved such services; (2) the Contractor authorizes those services in accordance with the provisions of the Health Plan; (3) the Contractor did not respond to the request for prior authorization within one hour of the request; (4) the Contractor cannot be contacted; or (5) the Contractor’s representative and the treating physician cannot reach an agreement concerning the enrollee’s care and the Contractor’s physician is not available for consultation. In this situation, the Contractor must give the treating physician the opportunity to consult with a Plan physician and the treating physician may continue with the care of the patient until a Plan physician is reached or one of the criteria of 42 C.F.R. §422.113(c) is met. The requirements of Federal and State law governing Post- Stabilization Care Services will be provided to members in clear, accurate, and standardized form at the time of enrollment and annually thereafter.

Post-Stabilization Care Services. (i) DVHA must cover post-stabilization care services obtained within or outside DVHA’s provider network that are: (1) Pre-approved by a DVHA provider or representative; or (2) Not pre-approved by a DVHA provider or representative but administered to maintain the beneficiary's stabilized condition within one hour of a request to DVHA for pre-approval of further post-stabilization care. (3) Not pre-approved but are administered to maintain, improve or resolve a beneficiary’s stabilized condition if: a. DVHA does not respond to a request for pre-approval within one hour; b. DVHA cannot be contacted; or c. DVHA’s representative and the treating physician cannot agree concerning the beneficiary’s treatment and DVHA does not have a physician available for consultation. In this situation, DVHA must allow the treating physician to continue with the care of the beneficiary until the DVHA physician is reached or the beneficiary is discharged. (ii) DVHA’s financial responsibility for post-stabilization services for services it has not pre-approved ends when any of the following conditions are met: (1) DVHA-contracted physician who has privileges at the treating hospital assumes responsibility for the beneficiary’s care; (2) DVHA-contracted physician assumes responsibility for the beneficiary’s care through transfer; (3) DVHA and the treating physician reach an agreement concerning the beneficiary’s care; or DocuSign Envelope ID: F73EF454-508D-44AC-ABD8-2A528194331A (4) The beneficiary is discharged. (iii) DVHA shall limit charges to beneficiaries for post-stabilization care services to an amount no greater than what DVHA would charge the beneficiary if the beneficiary had obtained the services through DVHA.

Post-Stabilization Care Services. Covered services related to the Enrollee's underlying condition that are provided after an Enrollee’s Emergency Medical Condition has been Stabilized and/or under the circumstances described in 42 CFR 438.114(e).

Post-Stabilization Care Services. Covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain, improve or resolve the enrollee's condition pursuant to 42 CFR 422.113. Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid recipient who is subject to mandatory assignment or one who may voluntarily elect to enroll in a given Managed Care Plan, but is not yet actually enrolled in a managed care plan. Preadmission Screening and Resident Review (PASRR) — Pursuant to 42 CFR Part 483, the process of screening and determining if nursing facility services and specialized mental health services or mental retardation services are needed by nursing facility applicants and residents. A DCF Office of Mental Health contractor completes the Level II reviews for those residents identified as having a mental illness. Agency for Persons with Disabilities staff complete reviews for those residents identified with a diagnosis of mental retardation. Pre-Enrollment — The provision of marketing materials to a Medicaid recipient.

Post-Stabilization Care Services. 2.10.10.1. The Contractor must cover and pay for Post-Stabilization Care Services. 2.10.10.2. The Contractor is financially responsible for Post- Stabilization Care Services obtained within or outside the organization that are pre-approved by a Contractor’s provider or other Contractor representative. 2.10.10.3. The Contractor is financially responsible for Post- Stabilization Care Services obtained within or outside the Contractor’s organization that are not pre-approved by a Network Provider or other Contractor representative, but are administered to maintain the Enrollee’s stabilized condition within one (1) hour of a request to the Contractor for pre-approval of further Post-Stabilization Care Services. 2.10.10.4. The Contractor is financially responsible for Post- Stabilization Care Services obtained from within or outside the Contractor that are not pre-approved by a Network Provider or other Contractor representative, but administered to maintain, improve, or resolve the Enrollee’s stabilized condition if the Contractor: 2.10.10.4.1. Does not respond to a request for pre-approval within one (1) hour; 2.10.10.4.2. Cannot be contacted; or 2.10.10.4.3. Or the Contractor’s representative and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Network Provider is not available for consultation. 2.10.10.4.4. In this situation, the Contractor must give the treating physician the opportunity to consult with a Network Provider and the treating physician may continue with care of the Enrollee until a Network Provider is reached or one of the criteria in 42 C.F.R.‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ 2.10.10.5. The Contractor must limit charges to Enrollees for Post- Stabilization Care Services to an amount no greater than what the Contractor would charge the Enrollee if he or she had obtained the services through the Contractor. 2.10.10.6. End of Contractor’s financial responsibility. The Contractor’s financial responsibility for Post-Stabilization Care Services it has not pre-approved ends when: 2.10.10.6.1. A Network Provider with privileges at the treating hospital assumes responsibility for the Enrollee’s care; 2.10.10.6.2. A Network Provider assumes responsibility for the Enrollee’s care through transfer;

Post-Stabilization Care Services. Covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain, improve or resolve the enrollee’s condition pursuant to 42 CFR 422.113. Potential Enrollee — Pursuant to 42 CFR 438.2, an eligible Medicaid recipient who is subject to mandatory assignment or who may voluntarily elect to enroll in a given Managed Care Plan, but is not yet an enrollee of a specific Managed Care Plan.