Post-Stabilization Services. The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. §438.114. The PH-MCO must limit charges to Members for Post-Stabilization Services to an amount no greater than what the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. The PH-MCO must cover Post-Stabilization Services without authorization, and regardless of whether the Member obtains the services within or outside its Provider Network if any of the following situations exist:
a. The Post-Stabilization Services were administered to maintain the Member’s stabilized condition within one hour of Provider’s request to the PH-MCO for pre-approval of further Post-Stabilization Services.
b. The Post-Stabilization Services were not pre-approved by the PH-MCO because the PH-MCO did not respond to the Provider’s request for pre-approval of these Post-Stabilization Services within one (1) hour of the request.
c. The Post-Stabilization Services were not pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services.
d. The PH-MCO and the treating physician cannot reach an agreement concerning the Member’s care and a PH-MCO physician is not available for consultation. In this situation, the MCO must give the treating physician the opportunity to consult with a PH-MCO physician and the treating physician may continue with care of the patient until a PH-MCO physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is met. The PH-MCO’s financial responsibility for Post-Stabilization Services it has not pre-approved ends when:
a. A Network physician with privileges at the treating hospital assumes responsibility for the Member's care;
b. A Network physician assumes responsibility for the Member's care through transfer;
c. The PH-MCO and the treating physician reach an agreement concerning the Member's care; or
d. The Member is discharged.
Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), 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 following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;
Post-Stabilization Services. Medically necessary non-emergency services furnished to a member after he or she is stabilized following an emergency medical condition.
Post-Stabilization Services. Contractor shall cover Post-Stabilization Services provided by an Affiliated or non-Affiliated Provider in any of the following situations: (i) Contractor authorized such services; (ii) such services were administered to maintain the Enrollee’s Stabilized condition within one (1) hour after a request to Contractor for authorization of further Post-Stabilization Services; or (iii) Contractor does not respond to a request to authorize further Post-Stabilization Services within one (1) hour, Contractor could not be contacted, or Contractor and the treating Provider cannot reach an agreement concerning the Enrollee’s care and an Affiliated Provider is unavailable for a consultation, in which case the treating Provider must be permitted to continue the care of the Enrollee until an Affiliated Provider is reached and either concurs with the treating Provider’s plan of care or assumes responsibility for the Enrollee’s care.
Post-Stabilization Services. In accordance with 42 CFR 438.114(e) and IC 00-00-00-00, the Contractor must cover post-stabilization services. Post-stabilization services are covered services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or, to improve or resolve the member's condition. The requirements at 42 CFR 422.113(c) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ 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 plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: A plan physician with privileges at the treating hospital assumes responsibility for the member's care; A plan physician assumes responsibility for the member's care through transfer; A Contractor representative and the treating physician reach an agreement concerning the member's care; or The member is discharged.
Post-Stabilization Services. Benefits and 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 this Section, to improve or resolve the Member’s condition (42 CFR § 438.114). The Contractor shall cover Post Stabilization Services in accordance with Section 1867 of the Social Security Act. The CONTRACTOR shall:
4.2.11.2.1. Cover benefits and services that may be required subsequent to a stabilization of a medical condition without Prior Authorization, including transfer of the individual to another facility.
4.2.11.2.2. Be responsible for payment to Providers—both In- network and out-of-network Service Area(s), without requiring prior approval, in accordance with the Social Security Act, Section 1867 (42 U.S.C. 1395 dd).
4.2.11.2.3. Cover Post Stabilization Services that were not pre- approved by the CONTRACTOR because the CONTRACTOR did not respond to the Provider of Post Stabilization Services request for pre-approval within one (1) hour after the request was made.
4.2.11.2.4. Cover Post- Stabilization Services if the CONTRACTOR could not be contacted for pre- approval.
4.2.11.2.5. Cover Post Stabilization Services if the CONTRACTOR and the treating Provider cannot reach an agreement concerning the Member’s care and a network Provider is not available for consultation. In this situation, the CONTRACTOR shall give the treating Provider the opportunity to consult with a CONTRACTOR’s network Provider, and the treating Provider may continue with the care of the Member until a network Provider is reached or one of the criteria of 42 CFR 422.113(c)(3) is met.
4.2.11.2.6. Limit charges to Members for any Post Stabilization Services to an amount no greater than what the charges would be if the Member had obtained the services through one of the CONTRACTOR’s network Providers.
4.2.11.2.7. Transfer of the individual to another medical facility within Social Security Act Section 1867 (42 U.S.C. 1395 dd) guidelines and other applicable state and federal regulations.
4.2.11.2.8. Be financially responsible for Post Stabilization Services it has not pre-approved until:
4.2.11.2.8.1. A CONTRACTOR’s network Provider with privileges at the treating hospital assumes responsibility for the Member’s care,
4.2.11.2.8.2. A CONTRACTOR’s network Provider assumes responsibility for the Member’s care through transfer,
4.2.11.2.8.3. A CONTRACTOR’s representative and the treatin...
Post-Stabilization Services. The PH-MCO must cover Post-Stabilization Services, pursuant to 42 CFR 438.114(b). The PH-MCO must limit charges to Members for Post-Stabilization Services to an amount no greater than what the PH-MCO would charge the Member if he or she had obtained the services through the PH-MCO. The PH-MCO must cover Post-Stabilization Services without requiring authorization, and regardless of whether the Member obtains the services within or outside the PH-MCO Provider Network if any of the following situations exist:
a. The Post-Stabilization Services were pre-approved by the PH-MCO.
b. The Post-Stabilization Services were administered to maintain the Member’s stabilized condition within one hour of Provider’s request to the PH-MCO for pre-approval of further Post-Stabilization Services.
c. The Post-Stabilization Services were not pre-approved by the PH-MCO because the PH-MCO did not respond to the Provider’s request for pre-approval of these Post- Stabilization Services within one (1) hour of the request.
Post-Stabilization Services. Post-stabilization services are services subsequent to an emergency that a treating physician views as medically necessary after an emergency medical condition has been stabilized. They are not "emergency services" and are subject to HMO's prior authorization process. HMO must be available to authorize or deny post-stabilization services within one hour after being contacted by the treating physician.
Post-Stabilization Services. Post stabilization care services are covered and paid for in accordance with provisions set forth at 42 CFR 422.113(c). Contractor is financially responsible for post-stabilization services obtained within or outside Contractor’s Network that are pre-approved by a plan Provider or other entity representative. Contractor is financially responsible for post-stabilization care services obtained within or outside Contractor’s Network that are not pre-approved by a Network Provider or other Contractor representative, but administered to maintain the enrollee's stabilized condition within one (1) hour of a request to Contractor for pre-approval of further post-stabilization care services.
Post-Stabilization Services. Contractor shall cover Post‐ Stabilization Services provided by a Network or non‐Network Provider in any of the following situations:
5.20.1.2.1 Contractor authorized such services;
5.20.1.2.2 such services were administered to maintain the Enrollee’s Stabilized condition within one (1) hour after a request to Contractor for authorization of further Post‐Stabilization Services; or
5.20.1.2.3 Contractor does not respond to a request to authorize further Post‐Stabilization Services within one (1) hour, Contractor could not be contacted, or Contractor and the treating Provider cannot reach an agreement concerning the Enrollee’s care and a Network Provider is unavailable for a consultation, in which case the treating Provider must be permitted to continue the care of the Enrollee until a Network Provider is reached and either concurs with the treating Provider’s plan of care or assumes responsibility for the Enrollee’s care.
