Common use of Post-Stabilization Care Clause in Contracts

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 privileges at the treating hospital assumes responsibility for the enrollee’s care; • A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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 the MCO, provider or other managed care organization MCO representative, but administered to maintain, improve, or resolve the enrollee's ’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 ’s care and a plan the MCO physician is not available for consultation. In this situation, the managed care organization MCO 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 the MCO 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 through the MCO. The MCO’s financial responsibility for post-stabilization care services it has not pre-approved ends when: • A MCO physician with privileges at the treating hospital assumes responsibility for the enrollee’s care; or • A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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; • or  Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services 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 the MCO, provider or other managed care organization MCO representative, but administered to maintain, improve, or resolve the enrollee's ’s stabilized condition if: if – o The organization does not respond to a request for pre-approval within one (1) 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 ’s care and a plan the MCO physician is not available for consultation. In this situation, the managed care organization MCO 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 the MCO 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 through the MCO. The MCO’s financial responsibility for post-stabilization care services it has not pre-approved ends when: •  A MCO physician with privileges at the treating hospital assumes responsibility for the enrollee’s care; • or  A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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 the MCO, provider or other managed care organization MCO representative, but administered to maintain, improve, or resolve the enrollee's ’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 ’s care and a plan the MCO physician is not available for consultation. In this situation, the managed care organization MCO 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 the MCO 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 through the MCO. The MCO’s financial responsibility for post-stabilization care services it has not pre-approved ends when: •  A MCO physician with privileges at the treating hospital assumes responsibility for the enrollee’s care; • or  A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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 privileges at the treating hospital assumes responsibility for the enrollee’s care; •  A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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; or • Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services services’ request for pre-pre- approval within one (1) hour after being requested to approve such care or could not be contacted for pre- 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: if - o The organization does not respond to a request for pre-approval within one (1) 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 privileges at the treating hospital assumes responsibility for the enrollee’s care; • A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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; • or  Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services 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: if - o The organization does not respond to a request for pre-approval within one (1) 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 privileges at the treating hospital assumes responsibility for the enrollee’s care; •  A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.

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; • or  Were not pre-approved by the organization because the organization did not respond to the provider of post-stabilization care services services’ request for pre-pre- approval within one (1) hour after being requested to approve such care or could not be contacted for pre- 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: if - o The organization does not respond to a request for pre-approval within one (1) 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 privileges at the treating hospital assumes responsibility for the enrollee’s care; •  A MCO representative and the treating physician each reach an agreement concerning the enrollee’s care.