Skilled Nursing

imagesSkilled nursing care consists of those services that must be performed by a registered nurse or licensed practical (vocational) nurse, and meet all of the following criteria for skilled nursing services:

  • Pursuant to physician orders, the service(s) is so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse to achieve the medically desired result; and
  • The skilled nursing care must be provided on an intermittent or hourly basis; and
  • The skilled nursing service is not custodial in nature; and
  • The skilled nursing service(s) must be reasonable and necessary for the treatment of the illness or injury, that is, the services must be consistent with the unique nature and severity of the member’s illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practice, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last a long time.

Skilled home health nursing care is the provision of intermittent skilled services to a member in the home for the purpose of restoring and maintaining his or her maximal level of function and health. These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service.

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