Common use of Post-Stabilization Services Clause in Contracts

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. 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) hours24)-hours-a-day, seven (7) days7)-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) (C422.113(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. 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 4.6.2.1 The Contractor shall cover post- stabilization be responsible for providing Post-Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to an emergency medical condition Emergency Medical Condition, that are provided after a member Member is stabilized in order to maintain the stabilized conditionCondition, or or, pursuant to 42 CFR 438.114(e), to improve or resolve the member's condition. Member’s Condition. 4.6.2.2 The Contractor shall demonstrate to FSSA be responsible for payment for Post-Stabilization Services that it has a mechanism in place to be available to all emergency room providers twentyare Prior Authorized or Pre-four (24) hoursCertified by an In-a-dayNetwork Provider or organization representative, seven (7) days-a-week to respond regardless of whether they are provided within one hour to an emergency room provider’s request for authorization of continued treatment after or outside 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. network of Providers. 4.6.2.3 The Contractor is financially responsible for postPost-stabilization services Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are preadministered to maintain the Member’s stabilized Condition for one (1) hour while awaiting response on a Pre-approved by a plan provider Certification or Contractor representative. Prior Authorization request. 4.6.2.4 The Contractor is also financially responsible for postPost-stabilization services 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: 4.6.2.4.1 The Contractor does not respond to the Provider’s request for pre-approved but administered to a member to maintain the stabilized condition certification or prior authorization within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. hour; 4.6.2.4.2 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) contacted; or 4.6.2.4.3 The Contractor’s Representative and the Contractor and treating attending physician cannot reach an agreement concerning the members’ Member’s care and a Contractor CMO plan physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), situation the Contractor must shall give the treating physician the opportunity to consult with a plan an In-Network physician and the treating physician may continue with the care of the patient Member until a CMO plan physician is reached or one of the following conditions is criteria in Section 4.6.2.5 are met: ▪ A plan physician . 4.6.2.5 The Contractor’s financial responsibility for Post-Stabilization Services it has not approved will end when: 4.6.2.5.1 An In-Network Provider with privileges at the treating hospital assumes responsibility for the member's Member’s care; ▪ A plan physician ; 4.6.2.5.2 An In-Network Provider assumes responsibility for the member's Member’s care through transfer; 4.6.2.5.3 The Contractor’s Representative and the treating physician reach an agreement concerning the Member’s care; or 4.6.2.5.4 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. As described in In accordance with 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, ) and IC 1200-1500-1200-00, the Contractor shall must cover post- post-stabilization services. Post-stabilization services are covered services related to an emergency Emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or 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) (C422.113(c)(2)(iii), 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)-(iv422.113(c)(3), 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. The Contractor shall limit charges to members for post-stabilization care services to an amount no greater than what the Contractor would charge the enrollee if they obtained the services through the Contractor per 42 CFR 438.114(e) and 42 CFR 422.113(c)(2)(iv).

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- 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-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) (C422.113(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-pre- approval of further post-stabilization services. The Contractor must also reimburse for post-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. 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) (C422.113(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. 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 4.6.2.1 The Contractor shall cover post- stabilization be responsible for providing Post-Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to an emergency medical condition Emergency Medical Condition, that are provided after a member Member is stabilized in order to maintain the stabilized conditionCondition, or or, pursuant to 42 CFR 438.114(e), to improve or resolve the member's condition. Member’s Condition. 4.6.2.2 The Contractor shall demonstrate to FSSA be responsible for payment for Post-Stabilization Services that it has a mechanism in place to be available to all emergency room providers twentyare Prior Authorized or Pre-four (24) hoursCertified by an In-a-dayNetwork Provider or organization representative, seven (7) days-a-week to respond regardless of whether they are provided within one hour to an emergency room provider’s request for authorization of continued treatment after or outside 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. network of Providers. 4.6.2.3 The Contractor is financially responsible for postPost-stabilization services Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are preadministered to maintain the Member’s stabilized Condition for one (1) hour while awaiting response on a Pre-approved by a plan provider Certification or Contractor representative. Prior Authorization request. 4.6.2.4 The Contractor is also financially responsible for postPost-stabilization services 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: 4.6.2.4.1 The Contractor does not respond to the Provider’s request for pre-approved but administered to a member to maintain the stabilized condition certification or prior authorization within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. hour; 4.6.2.4.2 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) contacted; or 4.6.2.4.3 The Contractor’s Representative and the Contractor and treating attending physician cannot reach an agreement concerning the members’ Member’s care and a Contractor CMO plan physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), situation the Contractor must shall give the treating physician the opportunity to consult with a plan an In-Network physician and the treating physician may continue with the care of the patient Member until a CMO plan physician is reached or one of the following conditions is criteria in Section 4.6.2.5 are met: ▪ A plan physician . 4.6.2.5 The Contractor’s financial responsibility for Post-Stabilization Services it has not approved will end when: 4.6.2.5.1 An In-Network Provider with privileges at the treating hospital assumes responsibility for the member's Member’s care; ▪ A plan physician ; 4.6.2.5.2 An In-Network Provider assumes responsibility for the member's Member’s care through transfer; 4.6.2.5.3 The Contractor’s Representative and the treating physician reach an agreement concerning the Member’s care; or

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 4.6.2.1 The Contractor shall cover post- stabilization be responsible for providing Post-Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to an emergency medical condition Emergency Medical Condition, that are provided after a member Member is stabilized in order to maintain the stabilized conditionCondition, or or, pursuant to 42 CFR 438.114(e), to improve or resolve the memberMember's conditionCondition. Revised 5/19/2008 4.6.2.2 The Contractor shall demonstrate to FSSA be responsible for payment for Post-Stabilization Services that it has a mechanism in place to be available to all emergency room providers twentyare Prior Authorized or Pre-four (24) hoursCertified by an In-a-dayNetwork Provider or organization representative, seven (7) days-a-week to respond regardless of whether they are provided within one hour to an emergency room provider’s request for authorization of continued treatment after or outside 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. 's network of Providers. 4.6.2.3 The Contractor is financially responsible for postPost-stabilization services Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor's Provider network that are preadministered to maintain the Member's stabilized Condition for one (1) hour while awaiting response on a Pre-approved by a plan provider Certification or Contractor representative. Prior Authorization request. 4.6.2.4 The Contractor is also financially responsible for postPost-stabilization services 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: 4.6.2.4.1 The Contractor does not respond to the Provider's request for pre-approved but administered to a member to maintain the stabilized condition certification or prior authorization within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. hour; 4.6.2.4.2 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) contacted; or 4.6.2.4.3 The Contractor's Representative and the Contractor and treating attending physician cannot reach an agreement concerning the members’ Member's care and a Contractor CMO plan physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), situation the Contractor must shall give the treating physician the opportunity to consult with a plan an In-Network physician and the treating physician may continue with the care of the patient Member until a CMO plan physician is reached or one of the following conditions is criteria in Section 4.6.2.5 are met: ▪ A plan physician . 4.6.2.5 The Contractor's financial responsibility for Post-Stabilization Services it has not approved will end when: 4.6.2.5.1 An In-Network Provider with privileges at the treating hospital assumes responsibility for the memberMember's care; ▪ A plan physician ; 4.6.2.5.2 An In-Network Provider assumes responsibility for the memberMember's care through transfer; 4.6.2.5.3 The Contractor's Representative and the treating physician reach an agreement concerning the Member's care; or Revised 5/19/2008 4.6.2.5.4 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.