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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 77 / 83

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(2) general.

With respect to benefit restrictions

(i)

In

Subject to paragraph (c)(3) of this section, an issuer

may not restrict the benefits for any portion of a hospital length of stay required under paragraph (a) of this section in a manner that is less favorable than the benefits provided for any

preceding portion of the stay.

(ii) Example. illustrated by the

The rules of this following example:

paragraph

(b)(2)

are

Example.

(i)

An issuer subject to the requirements of this

section provides benefits for hospital lengths of stay in

connection with childbirth. cesarean section, the issuer

In the case of a delivery by automatically pays for the first

48

hours. With respect to each succeeding 24-hour period, the covered individual must call the issuer to obtain precertification from a utilization reviewer, who determines if an additional 24-hour period is medically necessary. If this approval is not obtained, the issuer will not provide benefits for any succeeding 24-hour period.

(ii)

In this Example, the requirement to obtain

precertification

for

the

two

24-hour

periods

immediately

following paragraph

the initial 48-hour stay is (b)(2) because benefits for

prohibited

by this

the latter

part of

the

stay

are for

restricted in a manner a preceding portion of

that is less favorable than benefits

the

stay.

(However,

this

section

does

not prohibit

an issuer

period after

the first

from requiring

96

hours.)

In

precertification addition, if the

for any issuer’s

utilization reviewer denied any mother or within the 96-hour stay, the issuer would (a) of this section.

her newborn benefits also violate paragraph

(3) directly

With respect or indirectly

to

attending

providers.

An issuer may not

(i) Penalize (for example, take disciplinary action against or retaliate against), or otherwise reduce or limit the compensation of, an attending provider because the provider furnished care to a covered individual in accordance with this section; or

77

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