CurrentAspirus ArisePolicy CP-AMCR24-OO1A

Post Stabilization Care - Medicare

Defines coverage and requirements for post-stabilization care services related to emergency medical conditions for Aspirus Medicare products, including when services are considered post-stabilization, scope of coverage (including worldwide emergency care), and certain exclusions.

Policy Summary

PayerAspirus Arise

PolicyPost Stabilization Care - Medicare

Policy CodePolicy CP-AMCR24-OO1A

Change TypeAnnual review (V2) — no material clinical changes

Effective DateJan 1, 2025

Next Review Date

Key ActionNo prior authorization is required for emergency and post-stabilization services; obtain authorization only for post-discharge care.

SourceLink

POLICY UPDATE CHANGES

Annual Review updated effective date, removed row from product, added bullets to Emergency services, updated disclaimer verbiage.

New policy Aspirus (initial creation) recorded in V1 coverage history.

Medicareproduct focus

Not requiredPrior auth (post-stabilization)

Not requiredPrior auth (emergency)

2history entries

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Post-Stabilization Care

General post-stabilization coverage

Covered when ALL of the following are met:

Post-stabilization coverage criteria: 1) Service is related to an emergency medical condition; 2) Service is provided after the member is stabilized; 3) Service is provided to maintain the stabilized condition or, in some circumstances, to improve or resolve the condition; 4) For cost-sharing, post-stabilization care begins when the patient is stabilized and the emergency ends.

Physician determination of stabilization is binding on the plan. Coverage ends when an in‑network plan physician with hospital privileges assumes responsibility, the member is discharged, or plan and treating physician reach agreement.

Worldwide emergency care

Worldwide emergency care applies with specific inclusions and exclusions:

Worldwide emergency coverage: 1) Emergency services furnished outside the U.S. and its territories are covered when provided by a qualified emergency services provider and are needed to evaluate or stabilize an emergency medical condition; 2) Post-stabilization services required to maintain the stabilized condition are covered; 3) Ground ambulance transportation to the nearest appropriate hospital for emergency care is covered; 4) Post-stabilization services end at discharge.

Exclusions apply (see exclusions below).

Worldwide emergency coverage exclusions: 1) Transportation back to the United States or its territories is not covered; 2) Air ambulance (fixed wing or rotary wing) outside the U.S. and its territories is not covered; 3) Prescriptions filled by pharmacies outside the United States are not covered.

These exclusions apply specifically to worldwide emergency care.

For worldwide emergency care, certain exclusions apply. Transportation back to the United States or its territories is not covered. In addition, air ambulance (fixed wing or rotary wing) outside the U.S. and its territories is not covered. Prescriptions filled by pharmacies located outside the United States are also excluded from coverage, even if obtained for a medical emergency. Emergency care and post-stabilization care are otherwise covered only within the U.S. and its territories.

No related policies are listed for this policy (Policy Number: None).

If a member requires inpatient care at an out-of-network hospital after their emergency condition is stabilized, coverage continues only if the member is returned to an in-network (network) hospital for ongoing care. The plan’s financial responsibility ends when an in‑network physician with privileges at the treating hospital assumes responsibility for the member’s care, the member is discharged, or the plan and treating physician reach agreement.

Coding and Billing References

CPT/HCPCS/ICD-10 (informational placeholder)mixed

No codes listed

Provider Actions, Authorizations, and Documentation

Prior Authorization

Prior authorization — not required for emergency and post-stabilization services

Prior authorization is not required for emergency services and for post-stabilization care provided to maintain or improve a stabilized emergency condition. Lack of prior authorization for emergency or post-stabilization services must not be used as a basis for claim denials.

Denial Risk

Out-of-network inpatient continuation risk

Post-stabilization care services are covered only while the member remains stabilized and related to the emergency medical condition. If a member requires inpatient care at an out‑of‑network hospital after stabilization, coverage for continued inpatient care requires return to a network hospital; continued coverage will terminate if the member does not transfer back to the network facility.

Applies to inpatient continuation after stabilization
Member must return to a network hospital for continued inpatient coverage

Definitions and Regulatory References

Emergency medical condition — prudent layperson standard and examples of severity

DefinitionAn emergency medical condition exists when acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in jeopardy to health, serious dysfunction, loss of limb or function, serious impairment of bodily functions, worsening condition, or risk of death.

Examples of severityJeopardy to health (including pregnant woman or unborn child), serious dysfunction of any bodily organ or part, loss of limb or loss of function of limb, serious impairment to bodily functions, injury/illness/severe pain that is worsening, or situations to prevent loss of life.

Standard appliedPrudent layperson standard — judged by what a person with average knowledge of health and medicine would reasonably expect.

Action implicationServices meeting this definition are treated as emergency services for coverage and cost-sharing purposes per policy provisions.

Background

Post-stabilization care services are those provided after a member with an emergency medical condition has been stabilized. These services are intended to maintain the stabilized condition and, in some cases, to improve or resolve the condition. A condition is considered stabilized when, within reasonable medical probability, no material deterioration is likely to result from discharge or transfer. The treating physician determines when a member is stabilized; that determination is binding on the plan. Cost sharing for necessary emergency services furnished out-of-network is the same as for services furnished in-network, and post-stabilization coverage is limited to services related to the emergency medical condition as described above.

Policy Development and Revision History

2024-10-08revisionLatest

Annual review: updated effective date, removed a product row, added bullets to Emergency services, and updated disclaimer verbiage.

2024-08-01creation

Policy created (V1) — new Aspirus coverage policy recorded.

Policy Summary

PayerAspirus Arise

PolicyPost Stabilization Care - Medicare

Policy CodePolicy CP-AMCR24-OO1A

Change TypeAnnual review (V2) — no material clinical changes

Effective DateJan 1, 2025

Next Review Date

Key ActionNo prior authorization is required for emergency and post-stabilization services; obtain authorization only for post-discharge care.

SourceLink

On This Page

Documentation Required

International claims documentation — itemized bill translated to English and U.S. currency for out-of-country reimbursement

For reimbursement of emergency and post‑stabilization charges incurred outside the United States and its territories, members must submit an itemized bill translated into English and converted to U.S. currency. Members should submit these documents to Aspirus Claims Reimbursement; services received abroad are typically paid at time of discharge and then submitted for reimbursement.

Itemized bill translated into English
All amounts converted to U.S. currency
Submit to Aspirus Claims Reimbursement

Prior Authorization

Post-discharge authorization requirement — post-discharge care not covered unless authorized by Aspirus

Post‑discharge care is not covered unless specifically authorized by Aspirus. Providers should obtain authorization prior to furnishing post‑discharge services to avoid denial of coverage.

Post‑discharge services require prior authorization by Aspirus

Note

Reference documentation — CMS regulations and policy development history

Reference materials and source documents used to develop this policy include CMS regulations and the policy development history. See the cited regulations for detailed federal requirements that informed this policy.

42 CFR 438.114
42 CFR 422.113
Policy development and revision history: V1 08/01/2024; V2 10/08/2024

Note

Provider action highlight

Providers should ensure timely communication with the plan and, when applicable, transfer patients to an in‑network provider to maintain coverage for post‑stabilization inpatient care. Failure to obtain required authorizations for post‑discharge services or to transfer to network facilities may result in denial of coverage.

Clinically stable — definition when no material deterioration is likely upon discharge or transfer

DefinitionClinically stable is the point in a member's condition when no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during discharge or transfer from the hospital.

TimingDetermination applies at the time of planned discharge or transfer and marks when post-stabilization services may begin for coverage purposes.

Coverage implicationIf clinically stable, ongoing services are considered post-stabilization and covered only per policy criteria (e.g., to maintain the stabilized condition).

Stabilization decision — treating physician's determination is binding on the health plan

AuthorityThe treating physician must decide when the member may be considered stabilized for transfer or discharge, and that decision is binding on the health plan.

Transfer disputesFor transfers between inpatient settings, a member or authorized representative who disagrees may request that the health plan pay for continued out-of-network services; appeal rights apply if the plan declines.

Decision considerationsStabilization decisions may be based on factors such as distance or the member's post-discharge need for care.

CMS regulatory definitions and rules for emergency and post-stabilization services (42 CFR 438.114; 42 CFR 422.113)

CitationsCMS regulatory references: 42 CFR 438.114 (Emergency and post-stabilization services) and 42 CFR 422.113 (Special rules for emergency, maintenance and post-stabilization care).

Use in documentationThese CMS rules are cited as source documentation when documenting emergency and post-stabilization services for coverage determinations.

Policy history referencePolicy development and revision history entries (V1 and V2) accompany these CMS references in the source documentation.