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Contract Management Specialist/Buyer: Hannah Wright Lucas
REGIONAL BEHAVIORAL HEALTH AUTHORITY SERVICES
1. Amendment Begin Date: July 01, 2004
2. Amendment End Date: June 30, 2005
SECTION
13. CRISIS SERVICES:
The
Contractor shall maintain a 24-hour, seven day a week crisis response service
for eligible and enrolled persons that meets all the timeline requirements and
has an adequate array of providers to provide all services identified in the
ADHS Provider Manual and Paragraph 3, Covered Services of this contract.
Emergency
medical services (e.g. crisis services) do not require prior authorization but shall be delivered in compliance with
R9-22-210, R9-31-210, R9-22-1205 and R9-31-1205 and the ADHS/DBHS Provider
Manual.
a. Coverage and
Payment for Emergency Behavioral Health Services:
i. The Contractor must ensure coverage and payment for
emergency medical services for Title XIX/Title XXI eligible and enrolled
persons regardless of whether the provider that furnishes the service has a
contract with the Contractor or a subcontracted provider.
iii. The Contractor cannot deny payment for
treatment obtained under either of the following circumstances:
(1)
An eligible or enrolled person had an emergency medical condition, including
cases in which the absence of medical attention would not have resulted in the
outcomes identified in the definition of emergency medical condition found in
42 CFR 438.114; or
(2)
A representative of the Contractor or a subcontracted provider instructs the
eligible or enrolled person to seek emergency medical services.
iv. The Contractor
or its subcontracted provider may not:
(1)
Limit what constitutes an emergency medical condition as defined in 42 CFR
438.114, on the basis of lists of diagnoses or symptoms;
(2)
Refuse to cover emergency medical services based on the failure of the
subcontracted provider, other provider, hospital or fiscal agent to notify the
Contractor or its subcontracted providers of the eligible or enrolled person’s
screening and treatment within 10 calendar days of presentation for emergency
services. This notification stipulation is only related to the provision of
emergency services in an inpatient hospital emergency room.
v. An eligible
or enrolled person who has an emergency medical condition may not be held
liable for payment of subsequent screening and treatment needed to diagnose the
specific condition or stabilize the patient.
vi. The
attending emergency physician, or the provider actually treating the eligible
or enrolled person, is responsible for determining when the person is
sufficiently stabilized for transfer or discharge, and such determination is
binding on the Contractor and its subcontractors.
vii. When Title XIX and Title XXI members present in
an emergency room setting, the member's AHCCCS acute care health plan is
responsible for all emergency medical services including triage, physician
assessment and diagnostic tests. The Contractor is responsible for psychiatric
and/or psychological consultations provided to Title XIX and Title XXI ADHS
enrolled members in emergency room settings.
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