Stabilization of an Emergency Medical Condition

20.4 – Stabilization of an Emergency Medical Condition (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) The physician treating the enrollee must decide when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the MAO. Refer to section 20.5 below for the MAO’s obligations regarding services provided following stabilization. Chapter 13 of the MMCM, “MA Beneficiary Grievances, Organization Determinations, and Appeals,” addresses the enrollee’s right to request a Quality Improvement Organization review of hospital discharges to a lower level of care. For transfers from one inpatient setting to another inpatient setting, an enrollee or person authorized to act on his or her behalf who disagrees with the decision and believes the enrollee cannot safely be transferred may request that the organization pay for continued out-of-network services. If the MAO declines to pay for the services, appeal rights are available to the enrollee.