Common use of Responsibility for Payment of Authorized Services Clause in Contracts

Responsibility for Payment of Authorized Services. The PIHP shall be responsible for payment for services that the PIHP authorizes, including Medicaid substance abuse services. This provision presumes the PIHP and its agents are fulfilling their responsibility to individuals according to terms specified in the contract. Services shall not be delayed or denied as a result of a dispute of payment responsibility between two or more PIHPs. In the event there is an unresolved dispute between XXXXx, either party may request MDCH involvement to resolve the dispute, and MDCH will make such determination. Likewise, services shall not be delayed or denied as a result of a dispute of payment responsibility between the PIHP and another agency. The PIHP must be contacted for authorization for post-stabilization specialty care. The PIHP is financially responsible for post-stabilization specialty care services obtained within or outside the PIHP that are pre-approved by the PIHP or the plan provider if authorization is delegated to it by the PIHP. The PIHP is also responsible for post-stabilization specialty care services when they are administered to maintain, improve, or resolve the beneficiary’s stabilized condition when: a) The PIHP does not respond to a request for pre-approval within 1 hour; b) The PIHP cannot be contacted; or c) The PIHP representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a PIHP physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with a PIHP physician and the treating physician may continue with care of the patient until a PIHP physician is reached or one of the criteria of 42 CFR 422.133(c)(3) is met. When the DHS office in the PIHP's service area places a child outside of the service area on a non-permanent basis and the child needs specialty supports and services, the PIHP retains responsibility for services unless the family relocates to another service area, in which case responsibility transfers to the PIHP where the family has relocated.

Responsibility for Payment of Authorized Services. The PIHP shall be responsible for payment for services that the PIHP authorizes, including Medicaid substance abuse services. This provision presumes the PIHP and its agents are fulfilling their responsibility to individuals according to terms specified in the contract. Services shall not be delayed or denied as a result of a dispute of payment responsibility between two or more PIHPs. In the event there is an unresolved dispute between XXXXxPIHPs, either party may request MDCH involvement to resolve the dispute, and MDCH will make such determination. Likewise, services shall not be delayed or denied as a result of a dispute of payment responsibility between the PIHP and another agency. The PIHP must be contacted for authorization for post-stabilization specialty care. The PIHP is financially responsible for post-stabilization specialty care services obtained within or outside the PIHP that are pre-approved by the PIHP or the plan provider if authorization is delegated to it by the PIHP. The PIHP is also responsible for post-stabilization specialty care services when they are administered to maintain, improve, or resolve the beneficiary’s stabilized condition when: a) The PIHP does not respond to a request for pre-approval within 1 hour; b) The PIHP cannot be contacted; or c) The PIHP representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a PIHP physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with a PIHP physician and the treating physician may continue with care of the patient until a PIHP physician is reached or one of the criteria of 42 CFR 422.133(c)(3) is met. When the DHS office in the PIHP's service area places a child outside of the service area on a non-permanent basis and the child needs specialty supports and services, the PIHP retains responsibility for services unless the family relocates to another service area, in which case responsibility transfers to the PIHP where the family has relocated.422.133(c)

Responsibility for Payment of Authorized Services. The PIHP directly or through sub-contracting with the PIHP Mental Health and Substance Abuse Provider Network shall be responsible for payment for services that the PIHP authorizes, including Medicaid ABW mental health and substance abuse services. This provision presumes the PIHP and its agents are fulfilling their responsibility to individuals according to terms specified in the contract. Services shall not be delayed or denied as a result of a dispute of payment responsibility between two or more PIHPs. In the event there is an unresolved dispute between XXXXx, either party may request MDCH involvement to resolve the dispute, and MDCH will make such determination. Likewise, services shall not be delayed or denied as a result of a dispute of payment responsibility between the PIHP and another agency. The PIHP must be contacted for authorization for post-stabilization specialty care. The PIHP is financially responsible for ABW Program post-stabilization specialty care services obtained within or outside the PIHP catchment’s area that are pre-approved by the PIHP or the plan provider if authorization is delegated to it by the PIHP. The PIHP is also responsible for post-stabilization specialty care services when they are administered to maintain, improve, or resolve the beneficiary’s stabilized condition when: a) The PIHP does not respond to a request for pre-approval within 1 hour; b) The PIHP cannot be contacted; or c) The PIHP representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a PIHP physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with a PIHP physician and the treating physician may continue with care of the patient until a PIHP physician is reached or one of the criteria of 42 CFR 422.133(c)(3438.114 (2) is met. When the DHS office in the PIHP's service area places a child outside of the service area on a non-permanent basis and the child needs specialty supports and services, the PIHP retains responsibility for services unless the family relocates to another service area, in which case responsibility transfers to the PIHP where the family has relocated.

Responsibility for Payment of Authorized Services. The PIHP shall be responsible for payment for services that the PIHP authorizes, including Medicaid substance abuse services. This provision presumes the PIHP and its agents are fulfilling their responsibility to individuals according to terms specified in the contract. Services shall not be delayed or denied as a result of a dispute of payment responsibility between two or more PIHPs. In the event there is an unresolved dispute between XXXXxPIHPs, either party one may request MDCH involvement to resolve the dispute, and MDCH will make such a determination. Likewise, services shall not be delayed or denied as a result of a dispute of payment responsibility between the PIHP and another agency. The PIHP must be contacted for authorization for post-stabilization specialty care. The PIHP is financially responsible for post-stabilization specialty care services obtained within or outside the PIHP that are pre-approved by the PIHP or the plan provider if authorization is delegated to it by the PIHP. The PIHP is also responsible for post-stabilization specialty care services when they are administered to maintain, improve, or resolve the beneficiary’s stabilized condition when: a) a. The PIHP does not respond to a request for pre-approval within 1 hour; b) b. The PIHP cannot be contacted; or c) c. The PIHP representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a PIHP physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with a PIHP physician and the treating physician may continue with care of the patient until a PIHP physician is reached or one of the criteria of 42 CFR 422.133(c)(3) is met. When the DHS office in the PIHP's service area places a child outside of the service area on a non-permanent basis and the child needs specialty supports and services, the PIHP retains responsibility for services unless the family relocates to another service area, in which case responsibility transfers to the PIHP where the family has relocated.

Responsibility for Payment of Authorized Services. The PIHP shall be responsible for payment for services that the PIHP authorizes, including Medicaid substance abuse services. This provision presumes the PIHP and its agents are fulfilling their responsibility to individuals according to terms specified in the contract. Services shall not be delayed or denied as a result of a dispute of payment responsibility between two or more PIHPs. In the event there is an unresolved dispute between XXXXxPIHPs, either party may request MDCH involvement to resolve the dispute, and MDCH will make such determination. Likewise, services shall not be delayed or denied as a result of a dispute of payment responsibility between the PIHP and another agency. The PIHP must be contacted for authorization for post-stabilization specialty care. The PIHP is financially responsible for post-stabilization specialty care services obtained within or outside the PIHP that are pre-approved by the PIHP or the plan provider if authorization is delegated to it by the PIHP. The PIHP is also responsible for post-stabilization specialty care services when they are administered to maintain, improve, or resolve the beneficiary’s stabilized condition when: a) The PIHP does not respond to a request for pre-approval within 1 hour; b) The PIHP cannot be contacted; or c) The PIHP representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a PIHP physician is not available for consultation. In this situation, the PIHP must give the treating physician the opportunity to consult with a PIHP physician and the treating physician may continue with care of the patient until a PIHP physician is reached or one of the criteria of 42 CFR 422.133(c)(3) is met. When the DHS FIA office in the PIHP's service area places a child outside of the service area on a non-permanent basis and the child needs specialty supports and services, the PIHP retains responsibility for services unless the family relocates to another service area, in which case responsibility transfers to the PIHP where the family has relocated.