Private Duty Nursing Services Clause Samples
The Private Duty Nursing Services clause defines the coverage and conditions under which private duty nursing care is provided to a patient, typically outside of a hospital setting. This clause outlines the eligibility criteria, such as medical necessity and physician authorization, and may specify limits on the number of hours or types of services covered, like skilled nursing care at home for individuals with complex medical needs. Its core function is to clarify the extent of insurance or service provider responsibility for private nursing care, ensuring that both parties understand when and how such services are available and covered.
Private Duty Nursing Services. This plan covers private duty nursing services, received in your home when ordered by a physician, and performed by a certified home healthcare agency. This plan covers these services when the patient requires continuous skilled nursing observation and intervention.
Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible
Private Duty Nursing Services. Private duty nursing services shall be provided by a person possessing a license and current registration from the NYS Education Department to practice as a registered professional nurse or licensed practical nurse. Private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private Practitioner. The location of nursing services may be in the Enrollee's home or in the hospital. Private duty nursing services are covered only when determined by the attending physician to be medically necessary. Nursing services may be intermittent, part-time or continuous and provided in accordance with the ordering physicians, or certified nurse practitioner's written treatment plan.
Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 20% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 20% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay When rendered by our designated telemedicine provider. $40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $100 20% - After deductible Lab and pathology services. $50 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent care services $150 The level of coverage is the same as network provider. Vision exam - One routine eye exam per member per plan year. $50 20% - After deductible Non-routine eye exam $50 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member und...
Private Duty Nursing Services. 1. Your Plan pays for Private Duty Nursing Services when You are an Inpatient and when the nurse is not related to You by blood, marriage or adoption.
2. Your Plan pays for Private Duty Nursing Services at the Coinsurance level and up to the limitations shown in the Schedule of Benefits. The Lifetime Maximum Payment for Inpatient Private Duty Nursing Services will also count toward the Lifetime Maximum Payment for all Benefits.
3. Your Plan does not pay for Outpatient Private Duty Nursing Services.
Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office 0% 20% - After deductible When rendered by our designated telemedicine provider. $15 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay
Private Duty Nursing Services. A. The Contractor shall perform PA reviews for all requests for Private Duty Nursing Services by Record Abstract Review. The policy for these services is in 8.323.4 NMAC, EPSDT Private Duty Nursing Services. These services are covered only for children under the age of 21 years. A case manager initiates the review with a letter, a history and physical examination report, a treatment plan, Early Periodic Screening and Diagnostic Treatment (EPSDT) Service Plan (a budget/authorization sheet), and other required documents. Each request usually contains a package of several services. Each “package” constitutes a single review.
B. The Contractor shall focus the review on the appropriateness of the treatment plan and the medical necessity of the requested services and service amounts. HSD will provide the medical necessity criteria.
C. If the Contractor determines that the documentation does not substantiate the medical necessity for the service, the request will be denied. The Contractor will reduce the amount of service requested (partial denial) if that amount exceeds the documented needs.
D. The Contractor shall complete the EPSDT Service Plan to document and communicate the review decision to the provider in accordance with policies and procedures approved by HSD.
Private Duty Nursing Services. Private duty nursing services provided by a person possessing a license and current registration from the NYS Education Department to practice as a registered professional nurse or licensed practical nurse. Private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private Practitioner. The location of nursing services may be in the Enrollee's home or in the hospital. Private duty nursing services are covered when determined by the attending physician to be medically necessary. Nursing services may be intermittent, part-time or continuous and provided in accordance with the ordering physician, registered physician assistant or certified nurse practitioner's written treatment plan. Dental care includes preventive, prophylactic and other routine dental care, services, supplies and dental prosthetics required to alleviate a serious health condition, including one which affects employability. Dental surgery performed in an ambulatory or inpatient setting is the responsibility of the Contractor whether dental services are a covered plan benefit, or not. Inpatient claims and referred ambulatory claims for dental services provided in an inpatient or outpatient hospital setting for surgery, anesthesiology, x-rays, etc. are the responsibility of the Contractor. In these situations, the professional services of the dentist are covered by Medicaid fee-for-service. The Contractor should set up procedures to prior approve dental services provided in inpatient and ambulatory settings. As described in Sections 10.9 and 10.18 of this Agreement. Enrollees may self-refer to Article 28 clinics operated by academic dental centers to obtain covered dental services. If Contractor's Benefit Package excludes dental services:
Private Duty Nursing Services. Must be performed by a certified home health care agency. 20% - After deductible 20% - After deductible** Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - After deductible**
Private Duty Nursing Services. Private duty nursing services provided by a person possessing a license and current registration from the NYS Education Department to practice as a registered professional nurse or licensed practical nurse. Private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private Practitioner. Private duty nursing services are covered when determined by the attending physician to be medically necessary. Nursing services may be intermittent, part-time or continuous and must be provided in an Enrollee's home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner's written treatment plan. Dental services include, but shall not be limited to, preventive, prophylactic and other routine dental care, services, supplies and dental prosthetics required to alleviate a serious health condition, including one which affects employability. Dental surgery performed in an ambulatory or inpatient setting is the responsibility of the Contractor whether dental services are a covered plan benefit, or not. Inpatient claims and referred ambulatory claims for dental services ancillary to dental surgery provided in an inpatient or outpatient hospital setting are the responsibility of the Contractor. In these situations, the professional services of the dentist are covered by Medicaid fee-for-service. The Contractor should set up procedures to prior approve dental services provided in inpatient and ambulatory settings. As described in Sections 10.9 and 10.18 of this Agreement, Enrollees may self-refer to Article 28 clinics'operated by academic dental centers to obtain covered dental services, If Contractor's Benefit Package excludes dental services: