Common use of Physician and other professional services Clause in Contracts

Physician and other professional services. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. PKU formulas and special food products Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Podiatric services Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Pregnancy and maternity care Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.