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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 74 / 83

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(ii) paragraph

In this Example 2, the 48-hour p (a)(1)(i) of this section ends at

eriod described in 7 p.m. on October 3.

Examp the indivi The child hospital. is not in

le 3.

(i)

A woman covered under

dual

market gives birth

by

vagina

later develops pneumonia

and

is

a

The attending provider determine connection with childbirth.

a policy issued in l delivery at home. dmitted to the s that the admission

(ii) requiremen admission

In this Example 3, the hospital ts of this section do not apply t to the hospital because the admis

length-of-stay

  • o

    the child’s

sion is not in

connection with childbirth. (4) Authorization not required

(i)

In general.

An

issuer

may

not

require

that

a

physician

or

other

health

care

provider obtain authorization from the issuer for prescribing the

hospital length of stay required under paragraph (a)(1) of this

section.

(See also paragraphs (b)(2) and (c)(3) of this

for rules and examples notice requirements.)

regarding

other

authorization

and

section certain

(ii)

Example.

The rule of this

paragraph

(a)(4)

is

illustrated

by

the

following

example:

Example.

(i) In the case of a delivery by cesarean section,

an issuer subject to the requirements of this section automatically provides benefits for any hospital length of stay

of

up

to

72

hours.

For

any

longer

stay,

the

issuer

requires

an

attending provider to complete a certificate of medical

necessity.

The issuer

certificate

of medical

then makes necessity,

a determination, whether a longer

based on stay is

the

medically

necessary.

(ii)

In this Example, the requirement that an attending

provider complete authorization for

a certificate of medical necessity the period between 72 hours and 96

to obtain hours

following

a

delivery

by

cesarean

section

is

prohibited

by

this

paragraph (a)(4). (5) Exceptions

(i) Discharge of mother.

If a decision to

discharge a mother earlier than the period specified in paragraph

74

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