Common use of Post-Stabilization Services Clause in Contracts

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. The PHCHC-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. §438.114. The PHCHC-MCO must limit charges to Members a Participant for Post-Stabilization Services to an amount no greater than what the PHCHC-MCO would charge the Member Participant if he or she had obtained the services through a Network Providerthe Network. The PHCHC-MCO must cover Post-Stabilization Services without authorization, and regardless of whether the Member Participant obtains the services within or outside of its Provider Network if any of the following situations existexists: a. The Post-Stabilization Services were administered to maintain the MemberParticipant’s stabilized condition within one (1) hour of the Provider’s request to the PHCHC-MCO for pre-approval of further Post-Stabilization Services. b. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the PHCHC-MCO did not respond to the Provider’s request for pre-pre- approval of these the Post-Stabilization Services within one (1) hour of the request. c. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the Provider could not reach the PHCHC-MCO to request pre-approval for the Post-Stabilization Servicespre- approval. d. The PHCHC-MCO and the treating physician cancould not reach an agreement concerning the MemberParticipant’s care and a PHCHC-MCO physician is not available for consultation. In this situation, the CHC-MCO must give the treating physician the opportunity to consult with a PHCHC-MCO physician physician, and the treating physician may continue with the care of the patient Participant until a PHCHC-MCO physician is reached or one of the criteria applicable to termination of PHa CHC-MCO’s financial responsibility described below is met. The PHCHC-MCO’s financial responsibility for Post-Stabilization Services it that the CHC-MCO has not pre-approved ends when: a. A Network physician with privileges at the treating hospital assumes responsibility for the Member's Participant’s care; b. A Network physician assumes responsibility for the Member's Participant’s care through transfer; c. The PHCHC-MCO and the treating physician reach an agreement concerning the Member's Participant’s care; or d. The Member Participant is discharged.

Post-Stabilization Services. The PHCHC-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. §438.114. The PHCHC-MCO must limit charges to Members a Participant for Post-Stabilization Services to an amount no greater than what the PHCHC-MCO would charge the Member Participant if he or she had obtained the services through a Network Providerthe Network. The PHCHC-MCO must cover Post-Stabilization Services without authorization, and regardless of whether the Member Participant obtains the services within or outside of its Provider Network if any of the following situations existexists: a. The Post-Stabilization Services were administered to maintain the MemberParticipant’s stabilized condition within one (1) hour of the Provider’s request to the PHCHC-MCO for pre-approval of further Post-Stabilization Services. b. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the PHCHC-MCO did not respond to the Provider’s request for pre-pre- approval of these the Post-Stabilization Services within one (1) hour of the request. c. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the Provider could not reach the PHCHC-MCO to request pre-approval for the Post-Stabilization Servicespre- approval. d. The PHCHC-MCO and the treating physician cancould not reach an agreement concerning the MemberParticipant’s care and a PHCHC-MCO physician is not available for consultation. In this situation, the CHC-MCO must give the treating physician the opportunity to consult with a PHCHC-MCO physician physician, and the treating physician may continue with the care of the patient Participant until a PHCHC-MCO physician is reached or one of the criteria applicable to termination of PHa CHC-MCO’s financial responsibility described below is met. The PHCHC-MCO’s financial responsibility for Post-Stabilization Services it that the CHC-MCO has not pre-approved ends whenendswhen: a. A Network physician with privileges at the treating hospital assumes responsibility for the Member's Participant’s care; b. A Network physician assumes responsibility for the Member's Participant’s care through transfer; c. The PHCHC-MCO and the treating physician reach an agreement concerning the Member's Participant’s care; or d. The Member Participant is discharged.

Post-Stabilization Services. 4.6.2.1 The PH-MCO must cover Contractor shall be responsible for providing Post-Stabilization Servicescare services twenty-four (24) hours a day, as defined seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 C.F.R. §438.114. CFR 438.114(e), to improve or resolve the Member’s Condition. 4.6.2.2 The PH-MCO must limit charges to Members Contractor shall be responsible for payment for Post-Stabilization Services to that are Prior Authorized or Pre-Certified by an amount no greater than what In-Network Provider or organization representative, regardless of whether they are provided within or outside the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. Contractor’s network of Providers. 4.6.2.3 The PH-MCO must cover Contractor is financially responsible for Post-Stabilization Services without authorizationobtained from any Provider, and regardless of whether the Member obtains the services they are within or outside its the Contractor’s Provider Network if any of the following situations exist: a. The Post-Stabilization Services were network that are administered to maintain the Member’s stabilized condition within Condition for one (1) hour of Provider’s request to the PHwhile awaiting response on a Pre-MCO for pre-approval of further Post-Stabilization ServicesCertification or Prior Authorization request. b. 4.6.2.4 The Contractor is financially responsible for Post-Stabilization Services were obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not pre-approved prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the PH-MCO because the PH-MCO did Member’s stabilized Condition if: · The Contractor does not respond to the Provider’s request for pre-approval of these Post-Stabilization Services certification or prior authorization within one (1) hour of the request. c. hour; · The Post-Stabilization Services were Contractor cannot pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. be contacted; or · The PH-MCO Contractor’s Representative and the treating attending physician cannot reach an agreement concerning the Member’s care and a PH-MCO CMO plan physician is not available for consultation. In this situation, situation the MCO must Contractor shall give the treating physician the opportunity to consult with a PHan In-MCO Network physician and the treating physician may continue with care of the patient Member until a PH-MCO CMO plan physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is in Section 4.6.2.5 are met. . 4.6.2.5 The PH-MCOContractor’s financial responsibility for Post-Stabilization Services it has not preapproved will end when: · An In-approved ends when: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's ’s care; b. A ; · An In-Network physician Provider assumes responsibility for the Member's ’s care through transfer; c. ; · The PH-MCO Contractor’s Representative and the treating physician reach an agreement concerning the Member's ’s care; or d. or · The Member is discharged. 4.6.2.6 In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider.

Post-Stabilization Services. The PHCHC-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §438.114. The PHCHC-MCO must limit charges to Members Participants for Post-Stabilization Services to an amount no greater than what the PHCHC-MCO would charge the Member Participant if he or she had obtained the services through a Network Providerthe Network. The PHCHC-MCO must cover Post-Stabilization Services without authorization, and regardless of whether the Member Participant 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 MemberParticipant’s stabilized condition within one hour of Provider’s request to the PHCHC-MCO for pre-approval of further Post-Stabilization Services. b. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the PHCHC-MCO did not respond to the Provider’s request for pre-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 PHCHC-MCO because the Provider could not reach the PHCHC-MCO to request pre-approval for the Post-Stabilization Servicespre- approval. d. The PHCHC-MCO and the treating physician cancould not reach an agreement concerning the MemberParticipant’s care and a PHCHC-MCO physician is not available for consultation. In this situation, the CHC-MCO must give the treating physician the opportunity to consult with a PHCHC-MCO physician and the treating physician may continue with the care of the patient until a PHCHC-MCO physician is reached or one of the criteria applicable to termination of PHa CHC-MCO’s financial responsibility described below is met. The PHCHC-MCO’s financial responsibility for Post-Stabilization Services it that the CHC-MCO has not pre-approved ends whenendswhen: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's Participant’s care; b. A Network CHC-MCO physician assumes responsibility for the Member's Participant’s care through transfer; c. The PHCHC-MCO and the treating physician reach an agreement concerning the Member's Participant’s care; or; d. The Member Participant is discharged.

Post-Stabilization Services. 4.6.2.1 The PH-MCO must cover Contractor shall be responsible for providing Post-Stabilization Servicescare services twenty-four (24) hours a day, as defined seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 C.F.R. §438.114. CFR 438.114(e), to improve or resolve the Member’s Condition. 4.6.2.2 The PH-MCO must limit charges to Members Contractor shall be responsible for payment for Post-Stabilization Services to that are Prior Authorized or Pre-Certified by an amount no greater than what In-Network Provider or organization representative, regardless of whether they are provided within or outside the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. Contractor’s network of Providers. 4.6.2.3 The PH-MCO must cover Contractor is financially responsible for Post-Stabilization Services without authorizationobtained from any Provider, and regardless of whether the Member obtains the services they are within or outside its the Contractor’s Provider Network if any of the following situations exist: a. The Post-Stabilization Services were network that are administered to maintain the Member’s stabilized condition within Condition for one (1) hour of Provider’s request to the PHwhile awaiting response on a Pre-MCO for pre-approval of further Post-Stabilization ServicesCertification or Prior Authorization request. b. 4.6.2.4 The Contractor is financially responsible for Post-Stabilization Services were obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not pre-approved prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the PH-MCO because the PH-MCO did Member’s stabilized Condition if: · The Contractor does not respond to the Provider’s request for pre-approval of these Post-Stabilization Services certification or prior authorization within one (1) hour of the request. c. hour; · The Post-Stabilization Services were Contractor cannot pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. be contacted; or · The PH-MCO Contractor’s Representative and the treating attending physician cannot reach an agreement concerning the Member’s care and a PH-MCO CMO plan physician is not available for consultation. In this situation, situation the MCO must Contractor shall give the treating physician the opportunity to consult with a PHan In-MCO Network physician and the treating physician may continue with care of the patient Member until a PH-MCO CMO plan physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is in Section 4.6.2.5 are met. . 4.6.2.5 The PH-MCOContractor’s financial responsibility for Post-Stabilization Services it has not preapproved will end when: · An In-approved ends when: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's ’s care; b. A ; · An In-Network physician Provider assumes responsibility for the Member's ’s care through transfer; c. ; · The PH-MCO Contractor’s Representative and the treating physician reach an agreement concerning the Member's ’s care; or d. or · The Member is discharged. 4.6.2.6 In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider. 4.6.2.7 The Contractor shall be responsible for providing Demonstration related Post Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to a Demonstration related Emergency Medical Condition, that are provided after a P4HB participant is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the P4HB Participant’s Condition. 4.6.2.8 The Contractor shall be responsible for payment for Demonstration related Post Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers. 4.6.2.9 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the P4HB participant’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request. 4.6.2.10 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if: · The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour; · The Contractor cannot be contacted; or · The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met. 4.6.2.11 The Contractor’s financial responsibility for Demonstration related Post-Stabilization Services it has not approved will end when: · An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care; · An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer; · The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or · The P4HB Participant is discharged. 4.6.2.12 In the event the P4HB Participant received the Demonstration related Post-Stabilization Services from a Provider outside the Contractor’s network; the Contractor is prohibited from charging the P4HB Participant more than she would be charged if she had obtained services through an In-Network Provider.

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. ‌ The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §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-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-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. The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §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-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-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. 7.5.9.5.1 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 Contractor shall pay Claims 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 Providerrendered by any Provider in accordance with applicable federal regulations. The PH-MCO must cover attending emergency room physician or other treating Provider shall be responsible for determining whether the Enrollee is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor with respect to its responsibility for coverage and payment. 7.5.9.5.2 An Enrollee who has been treated for an Emergency Condition shall not be held liable for any subsequent screening or treatment necessary to stabilize the Enrollee. 7.5.9.5.3 Any Post-Stabilization Services without authorization, Service that requires Prior Authorization shall be processed 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 granted by the PH-MCO because the PH-MCO did not respond to the Provider’s request for pre-approval of these Post-Stabilization Services Contractor within one (1) hour of the requestService Authorization Request. c. The 7.5.9.5.4 Any Post-Stabilization Services were Service that requires Prior Authorization shall be deemed authorized if, within one (1) hour of the Service Authorization Request, (i) the Prior Authorization is not pre-approved by granted, or (ii) the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. The PH-MCO Contractor and the treating physician cannot reach an agreement concerning the MemberEnrollee’s care and a PH-MCO physician Network Provider is not available for consultation. In this situationFor the avoidance of doubt, the MCO Contractor must give the treating physician the opportunity to consult with a PH-MCO physician Network Provider, and the treating physician may continue with care of the patient Enrollee until a PHNetwork Provider is reached. 7.5.9.5.5 For every Prior Authorization granted pursuant to Section 7.5.9.5.4 above, the Contractor shall (i) review the Service Authorization Request after the corresponding Post-MCO physician Stabilization Service has been rendered to determine whether the service was Medically Necessary, (ii) document its determination, and (iii) if it has determined that the service was Medically Necessary, submit the Claim to ASES in its next Claims Payment Report, in accordance with Sections 11.1.1.4 and 16.7 of this Contract. Notwithstanding the above, if the Contractor submits a Claim to ASES for a Post-Stabilization Service and later determines that the service was not Medically Necessary, the Contractor shall recoup any payment made with respect to such Claim from the Provider and return such amount to ASES. 7.5.9.5.6 ASES or the PMG shall be financially responsible for all Post-Stabilization Services, except that the Contractor shall be financially responsible for any Post-Stabilization Service that requires Prior Authorization with respect to which the Contractor does not follow the procedure established in Section 7.5.9.5.5 above and which is reached or one of the criteria applicable determined not to termination of PH-MCO’s financial responsibility described below is met. be Medically Necessary. 7.5.9.5.7 The PH-MCO’s financial responsibility Contractor shall not be financially responsible for Post-Stabilization Services that it has not pre-approved ends whenPrior Authorized with respect to any Enrollee for any period after: a. 7.5.9.5.7.1 A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's Enrollee’s care; b. 7.5.9.5.7.2 A Network physician Provider assumes responsibility for the Member's Enrollee’s care through transfer; c. The PH-MCO 7.5.9.5.7.3 A Contractor representative and the treating physician reach an agreement concerning the Member's Enrollee’s care; or d. 7.5.9.5.7.4 The Member Enrollee is discharged.

Post-Stabilization Services. ‌ The PHCHC-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §438.114. 438.114.‌ The PHCHC-MCO must limit charges to Members Participants for Post-Post- Stabilization Services to an amount no greater than what the PH-CHC- MCO would charge the Member Participant if he or she had obtained the services through a Network Provider. the Provider Network.‌ The PHCHC-MCO must cover Post-Stabilization Services without authorization, and regardless of whether the Member Participant obtains the services within or outside its Provider Network if any of the following situations exist:exist:‌ a. The Post-Stabilization Services were administered to maintain the MemberParticipant’s stabilized condition within one hour of Provider’s request to the PHCHC-MCO for pre-approval of further Post-Stabilization Services.Services.‌‌ b. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the PHCHC-MCO did not respond to the Provider’s request for pre-approval of these Post-Post- Stabilization Services within one (1) hour of the request.request.‌ c. The Post-Stabilization Services were not pre-approved by the PHCHC-MCO because the Provider could not reach the PH-CHC- MCO to request pre-approval for the Post-Stabilization Services.Services.‌ d. The PHCHC-MCO and the treating physician cancould not reach an agreement concerning the MemberParticipant’s care and a PHCHC-MCO physician is not available for consultation. In this situation, the CHC-MCO must give the treating physician the opportunity to consult with a PHCHC-MCO physician and the treating physician may continue with the care of the patient until a PHCHC-MCO physician is reached or one of the criteria applicable to termination of PHa CHC-MCO’s financial responsibility described below is met. met.‌ The PHCHC-MCO’s financial responsibility for Post-Stabilization Services it that the CHC-MCO has not pre-approved ends when:when:‌ a. A Network physician with privileges at the treating hospital assumes responsibility for the Member's care;Participant’s care;‌ b. A Network CHC-MCO physician assumes responsibility for the Member's Participant’s care through transfer;transfer;‌ c. The PHCHC-MCO and the treating physician reach an agreement concerning the Member's Participant’s care; oror‌ d. The Member Participant is discharged.discharged.‌

Post-Stabilization Services. 4.6.2.1 The PH-MCO must cover Contractor shall be responsible for providing Post-Stabilization Servicescare services twenty-four (24) hours a day, as defined seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 C.F.R. §438.114. CFR 438.114(e), to improve or resolve the Member’s Condition. 4.6.2.2 The PH-MCO must limit charges to Members Contractor shall be responsible for payment for Post-Stabilization Services to that are Prior Authorized or Pre-Certified by an amount no greater than what In-Network Provider or organization representative, regardless of whether they are provided within or outside the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. Contractor’s network of Providers. 4.6.2.3 The PH-MCO must cover Contractor is financially responsible for Post-Stabilization Services without authorizationobtained from any Provider, and regardless of whether the Member obtains the services they are within or outside its the Contractor’s Provider Network if any of the following situations exist: a. The Post-Stabilization Services were network that are administered to maintain the Member’s stabilized condition within Condition for one (1) hour of Provider’s request to the PHwhile awaiting response on a Pre-MCO for pre-approval of further Post-Stabilization ServicesCertification or Prior Authorization request. b. 4.6.2.4 The Contractor is financially responsible for Post-Stabilization Services were obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not pre-approved prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the PH-MCO because the PH-MCO did Member’s stabilized Condition if: • The Contractor does not respond to the Provider’s request for pre-approval of these Post-Stabilization Services certification or prior authorization within one (1) hour of the request. c. hour; • The Post-Stabilization Services were Contractor cannot pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. be contacted; or • The PH-MCO Contractor’s Representative and the treating attending physician cannot reach an agreement concerning the Member’s care and a PH-MCO CMO plan physician is not available for consultation. In this situation, situation the MCO must Contractor shall give the treating physician the opportunity to consult with a PHan In-MCO Network physician and the treating physician may continue with care of the patient Member until a PH-MCO CMO plan physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is in Section 4.6.2.5 are met. . 4.6.2.5 The PH-MCOContractor’s financial responsibility for Post-Stabilization Services it has not preapproved will end when: • An In-approved ends when: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's ’s care; b. A ; • An In-Network physician Provider assumes responsibility for the Member's ’s care through transfer; c. ; • The PH-MCO Contractor’s Representative and the treating physician reach an agreement concerning the Member's ’s care; or d. or • The Member is discharged. 4.6.2.6 In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider. 4.6.2.7 The Contractor shall be responsible for providing Demonstration related Post Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to a Demonstration related Emergency Medical Condition, that are provided after a P4HB participant is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the P4HB Participant’s Condition. 4.6.2.8 The Contractor shall be responsible for payment for Demonstration related Post Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers. 4.6.2.9 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the P4HB participant’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request. 4.6.2.10 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if: • The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour; • The Contractor cannot be contacted; or • The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met. 4.6.2.11 The Contractor’s financial responsibility for Demonstration related Post-Stabilization Services it has not approved will end when: • An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care; • An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer; • The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or • The P4HB Participant is discharged. 4.6.2.12 In the event the P4HB Participant received the Demonstration related Post-Stabilization Services from a Provider outside the Contractor’s network; the Contractor is prohibited from charging the P4HB Participant more than she would be charged if she had obtained services through an In-Network Provider.

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. e. If a Member’s condition has stabilized and the Member can be transported without suffering detrimental consequences or aggravating the Member’s condition, the Member may be relocated to another facility to receive continued care and treatment as necessary. 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. 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 's stabilized condition within one hour of Provider’s '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 '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 's care and a PH-MCO 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 's financial responsibility described below is met. The PH-MCO’s '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. 4.6.2.1 The PH-MCO must cover Contractor shall be responsible for providing Post-Stabilization Servicescare services twenty-four (24) hours a day, as defined seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 C.F.R. §438.114. CFR 438.114(e), to improve or resolve the Member’s Condition. 4.6.2.2 The PH-MCO must limit charges to Members Contractor shall be responsible for payment for Post-Stabilization Services to that are Prior Authorized or Pre-Certified by an amount no greater than what In-Network Provider or organization representative, regardless of whether they are provided within or outside the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. Contractor’s network of Providers. 4.6.2.3 The PH-MCO must cover Contractor is financially responsible for Post-Stabilization Services without authorizationobtained from any Provider, and regardless of whether the Member obtains the services they are within or outside its the Contractor’s Provider Network if any of the following situations exist: a. The Post-Stabilization Services were network that are administered to maintain the Member’s stabilized condition within Condition for one (1) hour of Provider’s request to the PHwhile awaiting response on a Pre-MCO for pre-approval of further Post-Stabilization ServicesCertification or Prior Authorization request. b. 4.6.2.4 The Contractor is financially responsible for Post-Stabilization Services were obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not pre-approved prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the PH-MCO because the PH-MCO did Member’s stabilized Condition if: · The Contractor does not respond to the Provider’s request for pre-approval of these Post-Stabilization Services certification or prior authorization within one (1) hour of the request. c. hour; · The Post-Stabilization Services were Contractor cannot pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. be contacted; or · The PH-MCO Contractor’s Representative and the treating attending physician cannot reach an agreement concerning the Member’s care and a PH-MCO CMO plan physician is not available for consultation. In this situation, situation the MCO must Contractor shall give the treating physician the opportunity to consult with a PHan In-MCO Network physician and the treating physician may continue with care of the patient Member until a PH-MCO CMO plan physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is in Section 4.6.2.5 are met. . 4.6.2.5 The PH-MCOContractor’s financial responsibility for Post-Stabilization Services it has not preapproved will end when: · An In-approved ends when: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's ’s care; b. A ; · An In-Network physician Provider assumes responsibility for the Member's ’s care through transfer; c. ; · The PH-MCO Contractor’s Representative and the treating physician reach an agreement concerning the Member's ’s care; or d. or · The Member is discharged. 4.6.2.6 In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider. 4.6.2.7 The Contractor shall be responsible for providing Demonstration related Post Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to a Demonstration related Emergency Medical Condition, that are provided after a P4HB participant is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the P4HB Participant’s Condition. 4.6.2.8 The Contractor shall be responsible for payment for Demonstration related Post Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers. 4.6.2.9 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the P4HB participant’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request. 4.6.2.10 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if: · The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour; · The Contractor cannot be contacted; or · The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met. 4.6.2.11 The Contractor’s financial responsibility for Demonstration related Post-Stabilization Services it has not approved will end when: · An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care; · An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer; · The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or · The P4HB Participant is discharged. 4.6.2.12 In the event the P4HB Participant received the Demonstration related Post-Stabilization Services from a Provider outside the Contractor’s network; the Contractor is prohibited from charging the P4HB Participant more than she would be charged if she had obtained services through an In-Network Provider.

Post-Stabilization Services. 4.6.2.1 The PH-MCO must cover Contractor shall be responsible for providing Post-Stabilization Servicescare services twenty-four (24) hours a day, as defined seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 C.F.R. §438.114. CFR 438.114(e), to improve or resolve the Member’s Condition. 4.6.2.2 The PH-MCO must limit charges to Members Contractor shall be responsible for payment for Post-Stabilization Services to that are Prior Authorized or Pre-Certified by an amount no greater than what In-Network Provider or organization representative, regardless of whether they are provided within or outside the PH-MCO would charge the Member if he or she had obtained the services through a Network Provider. Contractor’s network of Providers. 4.6.2.3 The PH-MCO must cover Contractor is financially responsible for Post-Stabilization Services without authorizationobtained from any Provider, and regardless of whether the Member obtains the services they are within or outside its the Contractor’s Provider Network if any of the following situations exist: a. The Post-Stabilization Services were network that are administered to maintain the Member’s stabilized condition within Condition for one (1) hour of Provider’s request to the PH-MCO for pre-approval of further Post-Stabilization Serviceswhile awaiting response on a Pre- Certification or Prior Authorization request. b. 4.6.2.4 The Contractor is financially responsible for Post-Stabilization Services were obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not pre-approved prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the PH-MCO because the PH-MCO did Member’s stabilized Condition if: • The Contractor does not respond to the Provider’s request for pre-approval of these Post-Stabilization Services pre- certification or prior authorization within one (1) hour of the request. c. hour; • The Post-Stabilization Services were Contractor cannot pre-approved by the PH-MCO because the Provider could not reach the PH-MCO request pre-approval for the Post-Stabilization Services. d. be contacted; or • The PH-MCO Contractor’s Representative and the treating attending physician cannot reach an agreement concerning the Member’s care and a PH-MCO CMO plan physician is not available for consultation. In this situation, situation the MCO must Contractor shall give the treating physician the opportunity to consult with a PHan In-MCO Network physician and the treating physician may continue with care of the patient Member until a PH-MCO CMO plan physician is reached or one of the criteria applicable to termination of PH-MCO’s financial responsibility described below is in Section 4.6.2.5 are met. . 4.6.2.5 The PH-MCOContractor’s financial responsibility for Post-Stabilization Services it has not preapproved will end when: • An In-approved ends when: a. A Network physician Provider with privileges at the treating hospital assumes responsibility for the Member's ’s care; b. A ; • An In-Network physician Provider assumes responsibility for the Member's ’s care through transfer; c. ; • The PH-MCO Contractor’s Representative and the treating physician reach an agreement concerning the Member's ’s care; or d. or • The Member is discharged. 4.6.2.6 In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider. 4.6.2.7 The Contractor shall be responsible for providing Demonstration related Post Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to a Demonstration related Emergency Medical Condition, that are provided after a P4HB participant is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the P4HB Participant’s Condition. 4.6.2.8 The Contractor shall be responsible for payment for Demonstration related Post Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers. 4.6.2.9 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the P4HB participant’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request. 4.6.2.10 The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if: • The Contractor does not respond to the Provider’s request for pre- certification or prior authorization within one (1) hour; • The Contractor cannot be contacted; or • The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met. 4.6.2.11 The Contractor’s financial responsibility for Demonstration related Post- Stabilization Services it has not approved will end when: • An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care; • An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer; • The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or • The P4HB Participant is discharged. 4.6.2.12 In the event the P4HB Participant received the Demonstration related Post- Stabilization Services from a Provider outside the Contractor’s network; the Contractor is prohibited from charging the P4HB Participant more than she would be charged if she had obtained services through an In-Network Provider.

Post-Stabilization Services. ‌ The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §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.MCO 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. ‌ The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §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. ‌ The PH-MCO must cover Post-Stabilization Services, as defined in 42 C.F.R. CFR §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 Providerthe Provider Network. 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-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-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 PH-MCO 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.