Post Stabilization Care - Medicare
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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.
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.
Coverage Criteria for Post-Stabilization Care
General post-stabilization coverage
Covered when ALL of the following are met:
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:
Exclusions apply (see exclusions below).
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
| No codes listed |
Provider Actions, Authorizations, and Documentation
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.
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
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
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
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
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.
Definitions and Regulatory References
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
Annual review: updated effective date, removed a product row, added bullets to Emergency services, and updated disclaimer verbiage.
Policy created (V1) — new Aspirus coverage policy recorded.
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