Covered Services and Services which Require Pre-Authorization

HOSPICE OF THE CHESAPEAKE

It is the policy of Hospice of the Chesapeake to provide the following services for patients covered under the Medicare/Medicaid/Champus Benefit.

COVERED SERVICES

o Nursing Care o Medical Social Services o Physician services (related to terminal illness) o Counseling services by Hospice of the Chesapeake personnel o Home Health Aide (HHA) and homemaker services o Physical therapy, occupational therapy, speech therapy o Bereavement counseling and follow-up o Volunteer support services o Medications related to the terminal diagnosis for palliation of symptoms which are included in Hospice of the Chesapeake formulary o Durable Medical Equipment as needed for patient comfort o Laboratory services necessary for palliative care o Spiritual care

All services and treatments rendered are by the Plan of Care which is determined by the Interdisciplinary Team. All services must be pre-authorized by the IDT.

SERVICES WHICH REQUIRE PRE-AUTHORIZATION

• Surgery • Major diagnostic workups • CT scans/MRI • Respiratory support (except oxygen and nebulizer treatments) • Liquid oxygen and oxylite • Renal Dialysis • Total Parenteral Nutrition (TPN) • Radiation therapy • Chemotherapy • Transfusion of blood and/or blood components • Specialized beds • Gamma knife procedure