Common use of Coverage/Prior Authorization Clause in Contracts

Coverage/Prior Authorization. UBH or Payor shall not deny coverage for emergency services if the symptoms presented by the Member and recorded by Provider indicate that an emergency medical condition exists, or for emergency services necessary to provide a Member with a medical examination and stabilizing treatment, regardless of whether prior authorization was obtained to provide those services. If UBH or Payor authorizes emergency services, UBH or Payor will not subsequently rescind or modify that authorization after provider renders the authorized care in good faith and pursuant to the authorization except for: (i) payments made as a result of misrepresentation, fraud, omission or clerical error; and (ii) copayment, coinsurance or deductible amounts that are the responsibility of the Member. Once the Member is stabilized, UBH or Payor may require prior authorization as a condition of further coverage for continuing treatment, specialty consultations, transfer arrangements or other medically necessary and appropriate care for the Member. For required post evaluation or post stabilization services immediately following treatment of an emergency medical condition, UBH or Payor shall provide access to an authorized representative 24 hours a day, seven days a week, if UBH or Payor require authorization for such services.