Conditions for Coverage. Hospice care services must be certified by CareFirst BlueChoice, provided by a Qualified Hospice Care Program, and meet the following conditions for coverage:
A. The Member must have a life expectancy of six (6) months or less;
B. The Member’s attending Primary Care Physician or other Contracting Physician must submit a written hospice care services plan of treatment to CareFirst BlueChoice;
C. The Member must meet the criteria of the Qualified Hospice Care Program;
D. The need and continued appropriateness of hospice care services must be certified by CareFirst BlueChoice as meeting the criteria for coverage in accordance with CareFirst BlueChoice utilization management requirements; and E Prior authorization has been obtained from CareFirst BlueChoice.
Conditions for Coverage. Skilled Nursing Facility care must be authorized or approved by CareFirst BlueChoice as meeting the following conditions for coverage: SAMPLE
A. The Member must be under the care of his or her Primary Care Physician or other Contracting Physician.
B. The admission to the Skilled Nursing Facility must be a substitute for hospital care (i.e., if the Member were not admitted to a Skilled Nursing Facility, he or she would have to be admitted to a hospital).
C. Skilled Nursing Facility benefits will not be provided in a facility that is used primarily as a rest home or a home for the aged, or in a facility for the care of drug addiction or alcoholism.
D. The Member must require Skilled Nursing Care or skilled rehabilitation services which are:
1. Required on a daily basis;
2. Not Custodial; and
3. Only provided on an inpatient basis.
E. Prior authorization has been obtained from CareFirst BlueChoice.
Conditions for Coverage. Hospice care services must be certified by CareFirst, provided by a Qualified Hospice Care Program, and meet the following conditions for coverage:
A. The Member must have a life expectancy of six (6) months or less;
B. The Member’s attending physician must submit a written hospice care services plan of treatment to CareFirst;
C. The Member must meet the criteria of the Qualified Hospice Care Program;
D. The need and continued appropriateness of hospice care services must be certified by CareFirst as meeting the criteria for coverage in accordance with CareFirst utilization management requirements.
Conditions for Coverage. Skilled Nursing Facility care must be authorized or approved by CareFirst as meeting the following conditions for coverage:
A. The admission to the Skilled Nursing Facility must be a substitute for hospital care (i.e., if the Member were not admitted to a Skilled Nursing Facility, he or she would have to be admitted to a hospital). SAMPLE
B. Skilled Nursing Facility benefits will not be provided in a facility that is used primarily as a rest home or a home for the aged, or in a facility for the care of drug addiction or alcoholism.
C. The Member must require Skilled Nursing Care or skilled rehabilitation services which are:
1. Required on a daily basis;
2. Not Custodial; and
3. Only provided on an inpatient basis.
Conditions for Coverage. Skilled Nursing Facility care must be authorized or approved by CareFirst BlueChoice as meeting the following conditions for coverage:
A. The Member must be under the care of his or her primary care physician or other Contracting Provider.
B. The admission to the Skilled Nursing Facility must be a substitute for hospital care (i.e., if the Member were not admitted to a Skilled Nursing Facility, he or she would have to be admitted to a hospital).
C. Skilled Nursing Facility benefits will not be provided in a facility that is used primarily as a rest home or a home for the aged, or in a facility for the care of drug addiction or alcoholism.
D. The Member must require Skilled Nursing Care or skilled rehabilitation services which are:
1. Required on a daily basis;
2. Not Custodial; and,
3. Only provided on an inpatient basis.
Conditions for Coverage. Benefits are provided when:
A. The Member must be confined to home due to a medical, non-psychiatric condition. “Home” cannot be an institution, convalescent home, or any facility which is primarily engaged in rendering medical or rehabilitative services to sick, disabled, or injured persons.
B. The Home Health Care Visits are a substitute for hospital care or for care in a Skilled Nursing Facility (i.e., if Home Health Care Visits were not provided, the Member would have to be admitted to a hospital or Skilled Nursing Facility).
C. The Member requires and continues to require Skilled Nursing Care or rehabilitation services in order to qualify for home health aide services or other types of Home Health Care Services.
D. The need for Home Health Care Services is not Custodial in nature.
E. Services of a home health aide, medical social worker, or registered dietician must be performed under the supervision of a licensed professional nurse (R.N. or L.P.N.).
F. All services must be arranged and billed by the Qualified Home Health Agency. Providers may not be retained directly by the Member.
G. The Member must be under the care of a Primary Care Physician or other Contracting Physician.
X. Xxxxx authorization has been obtained from CareFirst BlueChoice.
Conditions for Coverage. Benefits are provided when:
A. The Member must be confined to home due to a medical, non-psychiatric condition. "Home" cannot be an institution, convalescent home, or any facility which is primarily engaged in rendering medical or rehabilitative services to sick, disabled, or injured persons.
B. The Home Health Care Visits are a substitute for hospital care or for care in a Skilled Nursing Facility (i.e., if Home Health Care Visits were not provided, the Member would have to be admitted to a hospital or Skilled Nursing Facility).
C. The Member requires and continues to require Skilled Nursing Care or rehabilitation services in order to qualify for home health aide services or other types of Home Health Care Services.
D. The need for Home Health Care Services is not Custodial in nature.
Conditions for Coverage. For coverage, you must:
1. Cooperate fully with us and the Department of Justice. Coverage may be forfeited if you fail to cooperate honestly and fully in our investigation, settlement or defense, and recovery of loss from the claim. If coverage is forfeited, you will be informed in writing of our decision and the reason for the decision.
2. Comply with the terms and conditions of this policy manual.
Conditions for Coverage. Skilled Nursing Facility care must be authorized or approved by CareFirst BlueChoice as meeting the following conditions for coverage:
A. The Member must be under the care of his or her Primary Care Physician or other Contracting Physician to whom the Member was referred.
B. The admission to the Skilled Nursing Facility must be a substitute for a Hospital admission. Skilled Nursing Facility benefits will not be provided in a facility that is used primarily as a rest home or a home for the aged, or in a facility for the care of drug addiction or alcoholism.
C. The Member requires Skilled Nursing Care or skilled rehabilitation services that are required on a daily basis and can only be provided on an inpatient basis. Skilled Nursing Care means non-Custodial Care that requires licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) for performance.
Conditions for Coverage. Benefits are provided when a Member:
A. Is confined to home due to a medical, non-psychiatric condition. "Home" cannot be an institution, convalescent home or any facility which is primarily engaged in rendering
B. Receives home health visits as a substitute for hospital care or for care in a Skilled Nursing Facility (i.e., if home health visits were not provided, the Member would have to be admitted to a hospital or skilled nursing facility).
C. Requires and continues to require Skilled Nursing Care or rehabilitation services in order to qualify for home health aide services or other types of home health care.
D. Has a need for home health services that is not custodial in nature.
E. Is under the care of a Primary Care Physician or other physician to whom the Member was referred by a Primary Care Physician.
