48. Change to the agreement on forms for statutory health care
from April 1, 1995 (Annex 2 BMV-Ä)
Article 1 Changes to the explanations of the form
1. The form explanation for sample 12 changes as follows:
"Sample 12: Ordinance on home nursing
The basis of the regulation of home nursing is the home nursing guideline of the Federal Joint Committee (HKP guideline) including the list of prescribable measures in the annex to the guideline. In doing so, the information contained in the list (see column Comment) on the prescription must be observed and any special features (e.g. impairment of vision) specified in the prescription.
Services of the Psychiatric nursing according to § 4 of the HKP guideline are also prescribed on the pattern 12.
The prescription of home nursing is only permissible if the insured require medical treatment due to an illness and the Home nursing is part of the medical treatment plan. In addition, because of serious illness or because of acute worsening of an illness, in particular after hospital stay, after an outpatient operation or after an outpatient hospital treatment, supportive care services for basic care and domestic care can also be prescribed, provided that the insured person does not need care level 2 , 3, 4 or 5 within the meaning of SGB XI. The prerequisite for prescribing home nursing is that the contract doctor has personally verified the condition of the insured person and the necessity of home nursing, or that he / she is familiar with both from the ongoing treatment.
The prescription of home nursing is not permitted if the contract doctor is aware of it is that the insured person or person living in the household of the insured person can carry out the necessary measure (s). If this is only possible for sub-areas, prescription for these sub-areas is not permitted. 48. Change to the agreement on forms for statutory health care from April 1, 1995 (Annex 2 BMV-Ä) Article 1 Changes to the explanations of the form 1. The form explanation for sample 12 changes as follows: "Sample 12: Ordinance on home nursing The basis of the regulation of home nursing is the home nursing guideline of the Federal Joint Committee (HKP guideline) including the list of prescribable measures in the annex to the guideline. In doing so, the information contained in the list (see column Comment) on the prescription must be observed and any special features (e.g. impairment of vision) specified in the prescription. Services of the Psychiatric nursing according to § 4 of the HKP guideline are also prescribed on the pattern 12. The prescription of home nursing is only permissible if the insured require medical treatment due to an illness and the Home nursing is part of the medical treatment plan. In addition, because of serious illness or because of acute worsening of an illness, in particular after hospital stay, after an outpatient operation or after an outpatient hospital treatment, supportive care services for basic care and domestic care can also be prescribed, provided that the insured person does not need care level 2 , 3, 4 or 5 within the meaning of SGB XI. The prerequisite for prescribing home nursing is that the contract doctor has personally verified the condition of the insured person and the necessity of home nursing, or that he / she is familiar with both from the ongoing treatment. The prescription of home nursing is not permitted if the contract doctor is aware of it is that the insured person or person living in the household of the insured person can carry out the necessary measure (s). If this is only possible for sub-areas, prescription for these sub-areas is not permitted. The services requested by the insured by submitting the statutory health insurance prescription (back of sample 12a) require the approval of the health insurance company. Until its decision on approval, the health insurance company will cover the costs of the services prescribed by the contract doctor and provided by the nursing service if the prescription is presented to the health insurance company no later than the third working day following the issue. When filling in the fields, please note the following: The diagnosis (s) which medically justify the need for home nursing are to be given here. The diagnoses are to be encoded in accordance with ICD-10-GM.
Especially with the first prescription, period of 14 days should not be exceeded (see § 5 Paragraph 1 and 2 HKP Directive). If longer prescription period is required, the reason for this should result from the prescription-relevant diagnoses and the restrictions. Follow-up ordinances must be issued within the last three working days before the end of the prescribed period.
If there is need for home care as result of an accident, this must be stated here.
The period in which the measures are to be carried out is specified here. Retroactive ordinances are generally not permitted. Exceptional cases must be specifically justified.
These fields contain frequency (daily, weekly, monthly) and duration (from - to) of the measures to be carried out. Information on duration and frequency are based on the specifications of the HKP guideline. The indication "duration" for individual measures is only necessary if there is deviation from the duration of the entire prescription (see "from - to"). The information on the frequency "daily", "wtl.", "Monthly" can be used side by side in order to achieve clarity in the amount of prescriptions. If the prescribed measure can, for example, be carried out at the weekend by working person living in the household of the insured person, the frequency must be stated as "1 x daily" and "5 x wt.".
The services requested by the insured by submitting the statutory health insurance prescription (back of sample 12a) require the approval of the health insurance company. Until its decision on approval, the health insurance company will cover the costs of the services prescribed by the contract doctor and provided by the nursing service if the prescription is presented to the health insurance company no later than the third working day following the issue.
When filling in the fields, please note the following:
The diagnosis (s) which medically justify the need for home nursing are to be given here. The diagnoses are to be encoded in accordance with ICD-10-GM.
Especially with the first prescription, period of 14 days should not be exceeded (see § 5 Paragraph 1 and 2 HKP Directive). If longer prescription period is required, the reason for this should result from the prescription-relevant diagnoses and the restrictions. Follow-up ordinances must be issued within the last three working days before the end of the prescribed period.
If there is need for home care as result of an accident, this must be stated here.
The period in which the measures are to be carried out is specified here. Retroactive ordinances are generally not permitted. Exceptional cases must be specifically justified.
These fields contain frequency (daily, weekly, monthly) and duration (from - to) of the measures to be carried out. Information on duration and frequency are based on the specifications of the HKP guideline. The indication "duration" for individual measures is only necessary if there is deviation from the duration of the entire prescription (see "from - to"). The information on the frequency "daily", "wtl.", "Monthly" can be used side by side in order to achieve clarity in the amount of prescriptions. If the prescribed measure can, for example, be carried out at the weekend by working person living in the household of the insured person, the frequency must be stated as "1 x daily" and "5 x wt.".
Treatment care includes measures of medical treatment that serve to treat diseases to cure, prevent their aggravation or alleviate the symptoms of illness and which can usually be delegated to nurses. Treatment care as precautionary care has the goal of enabling outpatient medical treatment and ensuring its result.
The measures that can be prescribed can be found in the list of services in the HKP guidelines.
When prescribing medication administration, no. 26 of the specifications of the HKP guideline must be observed . The individual preparations to be administered must be clear from this medical prescription (sample 12). The associated duration and frequency of the medication administration must also be specified. The information on the preparations can alternatively be given in separate document as an attachment to the prescription.
When prescribing blood sugar measurement services, No. 11 of the list of services of the HKP guideline must be observed. A distinction must be made as to whether the blood glucose test is due to an initial or new setting or an intensified insulin therapy.
When prescribing compression treatment services, No. 31 of the list of services of the HKP guideline must be observed. Compression treatment can be prescribed as part of home nursing care from compression class I.
When prescribing wound care services, No. 31 of the list of services of the HKP guidelines must be observed. The individual preparations to be used must be derived from this medical prescription (sample 12). The associated duration and frequency of the preparations to be used must also be specified. The information on the preparations and on the wound documentation can alternatively be made on separate document as an attachment to the prescription.
Measures other than those mentioned under 8. to 11. of the specifications of the HKP guideline can be prescribed here.
If the insured person and / or relatives are to be instructed in treatment care by the care service, this must be stated here, stating the individual treatment care services . Here No. 7 of the list of services of the HKP guideline must be observed.
Treatment care includes measures of medical treatment that serve to treat diseases to cure, prevent their aggravation or alleviate the symptoms of illness and which can usually be delegated to nurses. Treatment care as precautionary care has the goal of enabling outpatient medical treatment and ensuring its result.
The measures that can be prescribed can be found in the list of services in the HKP guidelines.
When prescribing medication administration, no. 26 of the specifications of the HKP guideline must be observed . The individual preparations to be administered must be clear from this medical prescription (sample 12). The associated duration and frequency of the medication administration must also be specified. The information on the preparations can alternatively be given in separate document as an attachment to the prescription.
When prescribing blood sugar measurement services, No. 11 of the list of services of the HKP guideline must be observed. A distinction must be made as to whether the blood glucose test is due to an initial or new setting or an intensified insulin therapy.
When prescribing compression treatment services, No. 31 of the list of services of the HKP guideline must be observed. Compression treatment can be prescribed as part of home nursing care from compression class I.
When prescribing wound care services, No. 31 of the list of services of the HKP guidelines must be observed. The individual preparations to be used must be derived from this medical prescription (sample 12). The associated duration and frequency of the preparations to be used must also be specified. The information on the preparations and on the wound documentation can alternatively be made on separate document as an attachment to the prescription.
Measures other than those mentioned under 8. to 11. of the specifications of the HKP guideline can be prescribed here.
If the insured person and / or relatives are to be instructed in treatment care by the care service, this must be stated here, stating the individual treatment care services . Here No. 7 of the list of services of the HKP guideline must be observed.
Basic care and household care can only be provided within the framework of support care or hospital avoidance care. In the context of security care, regulation of basic care and domestic care requires that the statutes of the health insurance provide for these services and that there is no need for care with care level 2, 3, 4 or 5 according to SGB XI.
The prescription of support care is in the case of serious illness or because of acute worsening of an illness, This is particularly possible after hospital stay, after an outpatient operation or after outpatient hospital treatment, provided there is no need for care with care level 2, 3, 4 or 5 according to SGB XI. Supportive care includes basic care and, if necessary, domestic care. A simultaneous need for medical treatment care is not necessary in this case. The entitlement to support care exists for up to four weeks per illness and can be extended by the health insurance company in justified exceptional cases after the MDK has been contacted.
If the requirements for support care are met, you must indicate whether basic care and, if applicable, household care should be provided. Domestic care services cannot be prescribed independently as part of supportive care, but only in connection with the necessary basic care. Basic care can be prescribed independently as part of supportive care.
Home nursing as hospital avoidance care can be prescribed if hospital treatment is necessary but not feasible. This is e.g. the case when insured persons refuse to consent to hospitalization. A prescription is also possible if this avoids hospital treatment. This is the case if, by supplementing outpatient medical treatment with home nursing measures, the otherwise necessary hospital treatment can be replaced or hospital treatment is shortened as result. Hospital avoidance care includes treatment and basic care as well as domestic care. The insured person's right to avoid hospital care is limited to four weeks and can be extended by the health insurance company in justified exceptional cases after the MDK has been contacted.
Basic care and household care can only be provided within the framework of support care or hospital avoidance care. In the context of security care, regulation of basic care and domestic care requires that the statutes of the health insurance provide for these services and that there is no need for care with care level 2, 3, 4 or 5 according to SGB XI.
The prescription of support care is in the case of serious illness or because of acute worsening of an illness, This is particularly possible after hospital stay, after an outpatient operation or after outpatient hospital treatment, provided there is no need for care with care level 2, 3, 4 or 5 according to SGB XI. Supportive care includes basic care and, if necessary, domestic care. A simultaneous need for medical treatment care is not necessary in this case. The entitlement to support care exists for up to four weeks per illness and can be extended by the health insurance company in justified exceptional cases after the MDK has been contacted.
If the requirements for support care are met, you must indicate whether basic care and, if applicable, household care should be provided. Domestic care services cannot be prescribed independently as part of supportive care, but only in connection with the necessary basic care. Basic care can be prescribed independently as part of supportive care.
Home nursing as hospital avoidance care can be prescribed if hospital treatment is necessary but not feasible. This is e.g. the case when insured persons refuse to consent to hospitalization. A prescription is also possible if this avoids hospital treatment. This is the case if, by supplementing outpatient medical treatment with home nursing measures, the otherwise necessary hospital treatment can be replaced or hospital treatment is shortened as result. Hospital avoidance care includes treatment and basic care as well as domestic care. The insured person's right to avoid hospital care is limited to four weeks and can be extended by the health insurance company in justified exceptional cases after the MDK has been contacted.
If the prerequisites for hospital avoidance care are met, it can also be specified whether, in addition to treatment care, basic care and / or domestic care are necessary.
< p>Basic care includes nursing aids in the areas of personal hygiene, nutrition and mobility. The measures required as part of basic maintenance may be described in more detail in the "Additional information" field. The services that can be prescribed are listed in the list of services of the HKP guideline (No. 1 - 4).
Domestic care includes domestic services in the home of the insured. The services are listed in the list of services of the HKP guideline (No. 5). “
2. The form explanation for sample 64 is changed as follows:
"Sample 64: Ordinance of medical care for mothers or fathers according to § 24 SGB V
On pattern 64, contract doctors can prescribe preventive medical care for mothers or fathers. These services can also be provided as mother-father-child services. The indication for the mother / father is decisive for their recommendation. The sample is available in the contracted doctor's practice.
Services for medical rehabilitation for mothers and fathers can be prescribed on sample 61 part B-D. In contrast to rehabilitation measure for mothers or fathers, there is no longer-term (> 6 months) activity impairment in the mother / father with preventive benefit for mothers or fathers.
When used of sample 64, it should be noted that the health insurance company only provides benefits for preventive medical care if there is sufficient physical and psychological resilience for the preventive benefit.
When filling in the fields, the following are required Notes to follow:
I. Preventive health disorders / illnesses
II.
If the prerequisites for hospital avoidance care are met, it can also be specified whether, in addition to treatment care, basic care and / or domestic care are necessary.
< p>Basic care includes nursing aids in the areas of personal hygiene, nutrition and mobility. The measures required as part of basic maintenance may be described in more detail in the "Additional information" field. The services that can be prescribed are listed in the list of services of the HKP guideline (No. 1 - 4).
Domestic care includes domestic services in the home of the insured. The services are listed in the list of services of the HKP guideline (No. 5). “
2. The form explanation for sample 64 is changed as follows:
"Sample 64: Ordinance of medical care for mothers or fathers according to § 24 SGB V
On pattern 64, contract doctors can prescribe preventive medical care for mothers or fathers. These services can also be provided as mother-father-child services. The indication for the mother / father is decisive for their recommendation. The sample is available in the contracted doctor's practice.
Services for medical rehabilitation for mothers and fathers can be prescribed on sample 61 part B-D. In contrast to rehabilitation measure for mothers or fathers, there is no longer-term (> 6 months) activity impairment in the mother / father with preventive benefit for mothers or fathers.
When used of sample 64, it should be noted that the health insurance company only provides benefits for preventive medical care if there is sufficient physical and psychological resilience for the preventive benefit.
When filling in the fields, the following are required Notes to follow:
I. Preventive health disorders / illnesses
II.Prevention requirement
In this section, the context factors relevant to the problem situation specific to the mother / father are queried for the anamnesis and the temporary impairments of activities / participation.
There is need for provision on the one hand if the mother / father has influenceable risk factors or health disorders that are likely to lead to an illness in the foreseeable future.
On the other hand, there is also need for precautionary measures if, in the case of manifest (chronic) illness, impending impairment of activities is to be prevented, the occurrence of relapses or exacerbations is to be avoided or their severity is to be reduced or the progression of the disease is to be counteracted.
< p> When assessing the need for preventive care, the contextual factors affecting the health problem must be taken into account.Need for preventive care only exists if the complex (interdisciplinary, multi-dimensional) approach to preventive care is required in addition to curative care.
A. Brief information on the anamnesis
B. Temporary impairment of activities / participation as result of the diseases mentioned under IB
Participation indicates being involved in life situation , for example participation in family life, in the world of work or in the social environment. Impairments can include, for example, problems with shopping, cooking, relationships, raising children, at work or during leisure time.
C. Contextual factors that are important for the mother- / father-specific problem constellation are relevant
Contextual factors contribute to an understanding of the disease / disability-related effects of health problem.Prevention requirement
In this section, the context factors relevant to the problem situation specific to the mother / father are queried for the anamnesis and the temporary impairments of activities / participation.
There is need for provision on the one hand if the mother / father has influenceable risk factors or health disorders that are likely to lead to an illness in the foreseeable future.
On the other hand, there is also need for precautionary measures if, in the case of manifest (chronic) illness, impending impairment of activities is to be prevented, the occurrence of relapses or exacerbations is to be avoided or their severity is to be reduced or the progression of the disease is to be counteracted.
< p> When assessing the need for preventive care, the contextual factors affecting the health problem must be taken into account.Need for preventive care only exists if the complex (interdisciplinary, multi-dimensional) approach to preventive care is required in addition to curative care.
A. Brief information on the anamnesis
B. Temporary impairment of activities / participation as result of the diseases mentioned under IB
Participation indicates being involved in life situation , for example participation in family life, in the world of work or in the social environment. Impairments can include, for example, problems with shopping, cooking, relationships, raising children, at work or during leisure time.
C. Contextual factors that are important for the mother- / father-specific problem constellation are relevant
Contextual factors contribute to an understanding of the disease / disability-related effects of health problem.For example, both the conditions in the social area and one's own skills in connection with coping with the health problem and its effects are important (e.g. constant time pressure, financial worries). In the case of mothers and fathers, the context factors can develop special mother / father-specific burden due to the responsibility for bringing up children and thus lead to mother / father-specific problem constellation.
III. Medical treatment and other measures
In addition, it should be confirmed that the treatment goal cannot be achieved with further therapeutic treatments. This means that general supply of therapeutic products as well as the further prescription of an existing supply of medicinal products does not meet the treatment goal.
The documentation of the previous measures for the prevention and treatment of diseases in subsection B. should underline once again that the treatment goals have not been or cannot be achieved with the previous individual measures.
IV. Prevention goals
V. Referral recommendations
A. Recommended type of performance
A joint mother / father-child service comes into consideration, if with the mother / father there is an individual pension requirement and z. B.
● there is need for treatment for the child, d. H. it is in need of treatment or already suffers from chronic illness, has disability or psychological problem and can be treated according to this impairment (s) or
● stressed mother / father-child relationship should be improved or
● there are psychosocial reasons or the child must be looked after.For example, both the conditions in the social area and one's own skills in connection with coping with the health problem and its effects are important (e.g. constant time pressure, financial worries). In the case of mothers and fathers, the context factors can develop special mother / father-specific burden due to the responsibility for bringing up children and thus lead to mother / father-specific problem constellation.
III. Medical treatment and other measures
In addition, it should be confirmed that the treatment goal cannot be achieved with further therapeutic treatments. This means that general supply of therapeutic products as well as the further prescription of an existing supply of medicinal products does not meet the treatment goal.
The documentation of the previous measures for the prevention and treatment of diseases in subsection B. should underline once again that the treatment goals have not been or cannot be achieved with the previous individual measures.
IV. Prevention goals
V. Referral recommendations
A. Recommended type of performance
A joint mother / father-child service comes into consideration, if with the mother / father there is an individual pension requirement and z. B.
● there is need for treatment for the child, d. H. it is in need of treatment or already suffers from chronic illness, has disability or psychological problem and can be treated according to this impairment (s) or
● stressed mother / father-child relationship should be improved or
● there are psychosocial reasons or the child must be looked after.
A mother / father-child benefit is not considered if the child has its own indication of medical rehabilitation benefit. In these cases, medical rehabilitation benefits must be applied for or prescribed for the child at the expense of the DRV or GKV.
B. Information on children who are to be included
VI. Other information
A. Requirements for the facility
B. The service is urgently medically necessary before the statutory waiting period has expired
C. Others
D. Callback requested
3. The form explanation for sample 65 changes in No. 4 as follows:
Article 2 Entry into force
The changes come into effect with effect from 01.10.2018.
Berlin, August 17th
A mother / father-child benefit is not considered if the child has its own indication of medical rehabilitation benefit. In these cases, medical rehabilitation benefits must be applied for or prescribed for the child at the expense of the DRV or GKV.
B. Information on children who are to be included
VI. Other information
A. Requirements for the facility
B. The service is urgently medically necessary before the statutory waiting period has expired
C. Others
D. Callback requested
3. The form explanation for sample 65 changes in No. 4 as follows:
Article 2 Entry into force
The changes come into effect with effect from 01.10.2018.
Berlin, August 17th2018
National Association of Statutory Health Insurance Physicians, K.d.ö.R., Berlin
GKV-Spitzenverband, K.d.ö.R., Berlin
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