Common use of Other Contractor Clause in Contracts

Other Contractor. Liable Poststabilization Care Services (A) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside the Contractor’s network that are not pre-approved by a Contractor representative, but are administered to maintain the Enrollee’s stabilized condition within one hour of a request to the Contractor for pre- approval of further Poststabilization Care Services. (B) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside of the Contractor’s network that are not pre- approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s stabilized condition if: (1) the Contractor does not respond to a request for pre-approval within one hour of the request; (2) the Contractor cannot be contacted; or (3) the Contractor representative and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Contractor physician is not available for consultation. In this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with the care of the Enrollee until a Contractor physician is reached, or one of the following criteria, found in 42 CFR § 422.113(c)(3) is met: (i) a Contractor physician with privileges at the treating hospital assumes responsibility for the Enrollee’s care; (ii) a Contractor physician assumes responsibility for the Enrollee’s care; (iii) a Contractor representative and the treating physician reach an agreement concerning the Enrollee’s care; or (iv) the Enrollee is discharged.

Other Contractor. Liable Poststabilization Care Services (A) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside the Contractor’s network that are not pre-approved by a Contractor representative, representative but are administered to maintain the Enrollee’s stabilized condition within one hour of a request to the Contractor for pre- approval of further Poststabilization Care Services. (B) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside of the Contractor’s network that are not pre- approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s stabilized condition if: (1) the Contractor does not respond to a request for pre-approval within one hour of the request; (2) the Contractor cannot be contacted; or (3) the Contractor representative and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Contractor physician is not available for consultation. In this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with the care of the Enrollee until a Contractor physician is reached, or one of the following criteria, found in 42 CFR § 422.113(c)(3) is met: (i) a Contractor physician with privileges at the treating hospital assumes responsibility for the Enrollee’s care; (ii) a Contractor physician assumes responsibility for the Enrollee’s care; (iii) a Contractor representative and the treating physician reach an agreement concerning the Enrollee’s care; or (iv) the Enrollee is discharged.

Other Contractor. Liable Poststabilization Care Services (A) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside the Contractor’s 's network that are not pre-approved by a Contractor representative, representative but are administered to maintain the Enrollee’s 's stabilized condition within one hour of a request to the Contractor for pre- approval of further Poststabilization Care Services. (B) The Contractor is financially responsible for Poststabilization Care Services obtained within or outside of the Contractor’s 's network that are not pre- approved by a Contractor representative but are administered to maintain, improve or resolve the Enrollee’s 's stabilized condition if: (1) the Contractor does not respond to a request for pre-approval within one hour of the request; (2) the Contractor cannot be contacted; or (3) the Contractor representative and the treating physician cannot reach an agreement concerning the Enrollee’s 's care and a Contractor physician is not available for consultation. In ln this situation, the Contractor shall give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with the care of the Enrollee until a Contractor physician is reached, or one of the following criteria, found in 42 CFR § i 422.113(c)(3) is met: (i) a Contractor physician with privileges at the treating hospital assumes responsibility for the Enrollee’s 's care; (ii) a Contractor physician assumes responsibility for the Enrollee’s 's care; (iii) a Contractor representative and the treating physician reach an agreement concerning the Enrollee’s 's care; or (iv) the Enrollee is discharged.