Common use of Referrals Clause in Contracts

Referrals. When an enrollee’s PCP or other MCO representative instructs the beneficiary to seek emergency care in-network or out-of-network, the MCO is responsible for payment for the medical screening examination and for other Medically Necessary emergency services, without regard to whether the patient meets the prudent layperson standard described above. The MCO must promptly pay for all covered emergency services, including Medically Necessary testing to determine if a medical emergency exists, that are furnished by providers that do not have arrangements with the MCO. This includes emergency services provided by a non-participating provider when the time required to reach the MCO’s facilities, or the facilities of a provider with which the MCO has contracted would have meant risk of permanent damage to the enrollee’s health.

Referrals. When an enrollee’s PCP primary care physician or other MCO plan representative instructs the beneficiary to seek emergency care in-network or out-of-network, the MCO plan is responsible for payment for the medical screening examination and for other Medically Necessary medically necessary emergency services, without regard to whether the patient meets the prudent layperson standard described above. The MCO must shall promptly pay for all covered emergency services, including Medically Necessary medically necessary testing to determine if a medical emergency exists, that are furnished by providers that do not have arrangements with the MCO. This includes emergency services provided by a non-participating provider when the time required to reach the MCO’s facilities, or the facilities of a provider with which the MCO has contracted would have meant risk of permanent damage to the enrollee’s health.