Hysterectomies. 2.7.8.3.1 Hysterectomy shall mean a medical procedure or operation for the purpose of removing the uterus. The CONTRACTOR shall cover hysterectomies only if the following requirements are met: 2.7.8.3.1.1 The hysterectomy is medically necessary; 2.7.8.3.1.2 The member or her authorized representative, if any, has been informed orally and in writing that the hysterectomy will render the member permanently incapable of reproducing; and 2.7.8.3.1.3 The member or her authorized representative, if any, has signed and dated an “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form which is available on the Bureau of TennCare’s web site, prior to the hysterectomy. Informed consent shall be obtained regardless of diagnosis or age in accordance with federal requirements. The form shall be available in English and Spanish, and assistance shall be provided in completing the form when an alternative form of communication is necessary. Refer to “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form and instructions for additional guidance and exceptions. 2.7.8.3.2 The CONTRACTOR shall not cover hysterectomies under the following circumstances: 2.7.8.3.2.1 If it is performed solely for the purpose of rendering an individual permanently incapable of reproducing; 2.7.8.3.2.2 If there is more than one purpose for performing the hysterectomy, but the primary purpose is to render the individual permanently incapable of reproducing; or 2.7.8.3.2.3 It is performed for the purpose of cancer prophylaxis.
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Samples: Agreement for the Administration of Tenncare Select, Contractor Risk Agreement, Contractor Risk Agreement (Amerigroup Corp)
Hysterectomies. 2.7.8.3.1 Hysterectomy shall mean a medical procedure or operation for the purpose of removing the uterus. 2.7.7.3.1 The CONTRACTOR shall cover hysterectomies only if the following requirements are met:
2.7.8.3.1.1 2.7.7.3.1.1 The hysterectomy is medically necessary;
2.7.8.3.1.2 2.7.7.3.1.2 The member or her authorized representative, if any, has been informed orally and in writing that the hysterectomy will render the member permanently incapable of reproducing; and
2.7.8.3.1.3 2.7.7.3.1.3 The member or her authorized representative, if any, has signed and dated an a “ACKNOWLEDGMENT STATEMENT OF HYSTERECTOMY INFORMATIONRECEIPT OF INFORMATION CONCERNING HYSTERECTOMY” form which is available on the Bureau of TennCareTENNCARE’s web site, prior to the hysterectomy. Informed consent shall must be obtained regardless of diagnosis or age in accordance with federal requirements. The form shall be available in English and Spanish, and assistance shall must be provided in completing the form when an alternative form of communication is necessary. Refer to “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form and instructions for additional guidance and exceptions.
2.7.8.3.2 2.7.7.3.2 The CONTRACTOR shall not cover hysterectomies under the following circumstances:
2.7.8.3.2.1 2.7.7.3.2.1 If it is performed solely for the purpose of rendering an individual permanently incapable of reproducing;
2.7.8.3.2.2 2.7.7.3.2.2 If there is more than one purpose for performing the hysterectomy, but the primary purpose is to render the individual permanently incapable of reproducing; or
2.7.8.3.2.3 2.7.7.3.2.3 It is performed for the purpose of cancer prophylaxis.
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