Medical Social Service Visits


	UM Guidelines

Home Health Care

BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®

BCBST modification effective June 26, 2008*

Added:

Exceptions may be required to comply with EPSDT and TennCare regulations.

Description - Medical social services that are provided by a licensed medical social worker may be covered, if the home health services meet the qualifying criteria:

Verify coverage per “benefit summary”

The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and

The plan of care indicates how the services which are required necessitate the skills of a licensed social worker, and can be performed safely and effectively.

Principles:

Homebound status applies to these services when provided in the home setting.

These services are usually reviewed in a Case Management, Low Risk Case Management, or Transition of Care Area.

EXAMPLE:

A physician ordered an assessment by a medical social worker for a multiple sclerosis patient who was unable to move anything but her head and who had an indwelling catheter. The patient had experienced recurring urinary tract infections and multiple infected ulcers. The physician ordered medical social services after the home health nurse indicated to him that the home was not well cared for, the patient appeared to be neglected much of the time, and the relationship between the patient and family was very poor. The physician and HHA were concerned that social problems created by family caregivers were impeding the treatment of the recurring infections and ulcers. The assessment and follow-up for counseling both the patient and the family by a medical social worker were reasonable and necessary.

Sources

BlueCross BlueShield of Tennessee network physicians. April - June 2008.

Center of Medicare & Medicaid Services. (2003, October). Medicare Benefit Policy Manual: Home Health Services, Chapter 7, (40.1.2.3, 40.1.2.4 - 40.1.2.9, 40.1.2.1 - 40.1.2.2, 40.2.1 - 40.2.2, 40.2.4, 40.2.3, 50.3). Retrieved March 29, 2004 from http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Added:


	*Exceptions may be required to comply with EPSDT and TennCare regulations.* Description - Medical social services that are provided by a licensed medical social worker may be covered, if the home health services meet the qualifying criteria: Verify coverage per “benefit summary” The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and The plan of care indicates how the services which are required necessitate the skills of a licensed social worker, and can be performed safely and effectively. Principles: Homebound status applies to these services when provided in the home setting. These services are usually reviewed in a Case Management, Low Risk Case Management, or Transition of Care Area. EXAMPLE: A physician ordered an assessment by a medical social worker for a multiple sclerosis patient who was unable to move anything but her head and who had an indwelling catheter. The patient had experienced recurring urinary tract infections and multiple infected ulcers. The physician ordered medical social services after the home health nurse indicated to him that the home was not well cared for, the patient appeared to be neglected much of the time, and the relationship between the patient and family was very poor. The physician and HHA were concerned that social problems created by family caregivers were impeding the treatment of the recurring infections and ulcers. The assessment and follow-up for counseling both the patient and the family by a medical social worker were reasonable and necessary. Sources BlueCross BlueShield of Tennessee network physicians. April - June 2008. Center of Medicare & Medicaid Services. (2003, October). Medicare Benefit Policy Manual: Home Health Services, Chapter 7, (40.1.2.3, 40.1.2.4 - 40.1.2.9, 40.1.2.1 - 40.1.2.2, 40.2.1 - 40.2.2, 40.2.4, 40.2.3, 50.3). Retrieved March 29, 2004 from http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf.