MAO Financial Responsibility

20.5.2 – MAO Financial Responsibility (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) The MAO is financially responsible for post-stabilization care services obtained within or outside the MAO that: • Are pre-approved by a plan provider or other MAO representative; • Although not pre-approved by a plan provider or other MAO representative, are administered to maintain the enrollee’s stabilized condition within one hour of a request to the MAO for pre-approval of further post-stabilization care; or • Although not pre-approved by a plan provider or other MAO representative, are administered to maintain, improve, or resolve the enrollee’s stabilized condition when: o The MAO does not respond to a request for pre-approval within one hour; o The MAO cannot be contacted; or o The MAO representative and the treating physician cannot reach an agreement concerning the enrollee’s care, and a plan physician is not available for consultation. (In this situation, the MAO must give the treating physician the opportunity to consult with a plan physician. The treating physician may continue with care of the patient until a plan physician is reached or one of the criteria below is met.)