Post-Stabilization Care Services. The Contractor shall cover and pay for Post-Stabilization Care Services in accordance with the provisions of 42 C.F.R. § 422.113(c). The Contractor is financially responsible for Post-Stabilization Care Services obtained within the Contractor’s Provider Network or from an Out-of-network Provider that are not pre- approved by a Network Provider or other Contractor representative, but administered to maintain, improve or resolve the Member’s stabilized condition if:
1. The Contractor does not respond to a request for pre-approval within one hour;
2. The Contractor cannot be contacted; or
3. The Contractor representative and the treating physician cannot reach an agreement concerning the Member’s care and a Contractor physician is not available for consultation. In this situation, the Contractor must give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with care of the patient until a Contractor physician is reached or one of the criteria of 42 C.F.R. § 422.113 is met. The Contractor must not charge Members upon the end of Post-Stabilization Care Services that the Contractor has not provided service authorization. Post-Stabilization Care Services not approved by the Contractor end when:
1. A Contractor physician with privileges at the treating hospital assumes responsibility for the Member’s care;
2. A Contractor physician assumes responsibility for the Member’s care through transfer;
3. A Contractor representative and the treating physician reach an agreement concerning the Member’s care; or
4. The Member is discharged.
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. (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-
b. DVHA cannot be contacted; or
c. DVHA’s representative and the treating physician
(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
(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. 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 438.10(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. 1. Notwithstanding Title 9, CCR, Section 1830.220 regarding out-of-plan services, the Contractor is financially responsible for post-stabilizationcare services obtained within or outside the Contractor's provider network that:
a. Are prior authorized by the Contractor
b. Are not prior authorized by the Contractor, but are delivered by the provider to maintain the beneficiary's stabilized condition within one hour of an MHP payment authorization request for prior authorization of further post- stabilization care services;
c. Are not prior authorized by the Contractor, but are delivered to maintain, improve, or resolve the beneficiary's stabilized condition The Contractor does not respond to an MHP payment authorization request for prior authorization within one hour; The Contractor cannot be contacted; or The Contractor and the treating physician cannot reach an agreement concerning the beneficiary's care and a Contractor-designated physician is not available for consultation. In this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor- designated physician and the treating physician may continue with care of Xxxx County Mental Health and Abuse Services Exhibit A - Attachment 2 the beneficiary until a Contractor-designated physician is reached or one 041 2 of the criteria in paragraph 2. is met.
2. The Contractor's financial responsibility for post-stabilization care services it has not prior authorized ends when--
a. A Contractor-designated physician with privileges at the treating hospital assumes responsibility for the beneficiary's care;
b. A Contractor-designated physician assumes responsibility for the beneficiary's care through transfer;
c. The Contractor and the treating physician reach an agreement concerning the beneficiary's care; or
d. The beneficiary is discharged.
Post-Stabilization Care Services. Contracted Services, related to an Emergency Medical Condition, that are provided after a MA Member is stabilized in order to
(a) maintain the stabilized condition, or (b) to improve or resolve the MA Member’s condition, under specific circumstances generally relating to MA HEALTH PLAN’s pre- approval of the care, described at 42 CFR, 422.113(c)(2)(iii).
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 health plan, but is not yet actually enrolled in a health plan. Pre-Enrollment — The provision of marketing materials to a Medicaid recipient. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract Preferred Drug List – A listing of prescription products selected by a pharmaceutical and therapeutics committee as cost effective choices for clinician consideration when prescribing for Medicaid recipients.
