Prenatal Care Third Trimester. For Members entering the CONTRACTOR’s Health Plan in the third trimester of pregnancy who is receiving medically necessary covered prenatal care services the day before Enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services without any form of prior approval and without regard to whether such services are being provided by a contracted or out-of- network Provider.
Prenatal Care Third Trimester. For Members entering the CONTRACTOR’s Health Plan in the third trimester of pregnancy who is receiving medically necessary covered prenatal care services the day before enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services without any form of prior approval and without regard to whether such services are being provided by a contracted or out-of-network provider. Members Enrolled Upon Termination of Provider Contract In accordance with 42 CFR 430.10(f)(5), the CONTRACTOR must make a good faith effort to give written notice of termination of a contracted Provider, within fifteen (15) days after receipt or issuance of the termination notice, to each enrollee who received his or her primary care from, or was seen on a regular basis by, the terminated provider. Members with Appeals in Process The CONTRACTOR shall ensure the continuation of the Member’s benefits/services while an Appeal is in process if all of the conditions in Section 9 are satisfied and consistent with Federal Regulations [42 CFR 438.420(a); 42 CFR 438.420(b)].
