The [Member's] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. . Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if Home Health Care were not provided. The services and supplies must be: ordered by the [Member's] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. The home health care plan must be set up in writing by the [Member's] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member's] Practitioner at least once every 60 days. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year. ANY HOME HEALTH CARE SERVICES OR SUPPLIES A [MEMBER] RECEIVES AS A [NETWORK] SERVICE OR SUPPLY WILL REDUCE THE HOME HEALTH CARE BENEFIT AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. We will reduce benefits by 50% with respect to charges for treatment, services and supplies for Home Health Care which are not Pre-Approved by Us provided that benefits would otherwise be payable under this Contract. Practitioner's Charges for Non-Surgical Care and Treatment We cover Practitioner's charges for the Medically Necessary and Appropriate care and treatment of an Illness or Injury. Practitioner's Charges for Surgery We cover Practitioner's charges for Medically Necessary and Appropriate Surgery. [Carrier] does not pay for Cosmetic Surgery unless it is required as a result of an Illness or Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly.
The [Member's] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. . Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if Home Health Care were not provided. The services and supplies must be: ordered by the [Member's] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. The home health care plan must be set up in writing by the [Member's] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member's] Practitioner at least once every 60 days. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year. ANY HOME HEALTH CARE SERVICES OR SUPPLIES A [MEMBER] RECEIVES AS A [NETWORK] SERVICE OR SUPPLY WILL REDUCE THE HOME HEALTH CARE BENEFIT AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. We will reduce benefits by 50% with respect to charges for treatment, services and supplies for Home Health Care which are not Pre-Approved by Us provided that benefits would otherwise be payable under this Contract. Practitioner's Charges for Non-Surgical Care and Treatment We cover Practitioner's charges for the Medically Necessary and Appropriate care and treatment of an Illness or Injury. Practitioner's Charges for Surgery We cover Practitioner's charges for Medically Necessary and Appropriate Surgery. [Carrier] does not pay for Cosmetic Surgery unless it is required as a result of an Illness or Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly.
hmo_poscontract.docx