Obstetrics/Gynecology Professional Payment Policy doc

The following payment policy applies to Tufts Health Plan commercial contracted providers who render obstetrical and/or gynecological services.. Policy Tufts Health Plan covers medicall

The following payment policy applies to Tufts Health Plan commercial contracted providers who render

obstetrical and/or gynecological services This policy applies to commercial1 products

Note: Audit and disclaimer information is located at the end of this document

Policy

Tufts Health Plan covers medically necessary obstetrical and gynecological services, as described below

Services and subsequent payment are based on the member's benefit plan document Providers and

their office staff are required to use self-service channels to verify effective dates and copayments for

commercial members prior to initiating services

Refer to the Electronic Services section of our website for our self-service channel options Benefit

specifics should be verified prior to initiating services by logging on to our website or by contacting

Provider Services

Nuchal Translucency Testing

Tufts Health Plan covers the Nuchal Translucency test based upon the member's medical risk factor and

medical necessity as determined by the Obstetrician/Gynecologist This test does not require prior

authorization

Nuchal Translucency testing is done by ultrasound In combination with the testing of maternal blood for

free B-hCG and pregnancy associated plasma protein-A, a determination of the risk of Down syndrome

can be made This testing is also known as Early Risk Assessment (ERA), Ultrascreen, Firstlook or First

trimester screening

Gynecology

Tufts Health Plan members are covered for one routine gynecology visit per calendar year, any medically

necessary gynecological follow-up care identified at the examination, and any additional medically

necessary gynecological conditions Family planning services, including birth control counseling and

contraceptive management, genetic counseling, and termination of pregnancy are not part of the standard gynecology benefit Refer to the Family Planning Payment Policy for additional information

Preventive Services

Effective for new groups and existing groups when they renew on or after September 23, 2010, most

Tufts Health Plan employer groups will be required to provide all insured members 100% coverage for

preventive care services A minority of employers who have elected to maintain "grandfathered" status

under the Patient Protection and Affordable Care Act (commonly referred to as healthcare reform) are not

subject to this requirement However, many of these groups have opted to cover preventive services with

no cost sharing, and their “grandfathered” status may change over time

This means that most members will have no cost-sharing responsibility when preventive services are

rendered by an in-network provider Members may still be required to pay a copayment, deductible or

coinsurance for preventive services received from out-of-network providers (PPO and POS plans), or for

non-preventive services received in conjunction with a preventive services visit Please reference the

Preventive Services list for a complete list of services that have been deemed preventive in nature

1 Commercial products include HMO, POS, PPO & CareLinkSM when Tufts Health Plan is Primary Administrator

2

Eligibility is subject to retroactive reporting of disenrollment

Obstetrics/Gynecology

Professional Payment Policy

Member Responsibility

Copayments, deductible and/or coinsurance may apply pursuant to the member's benefit plan document

Maternity Services

Tufts Health Plan will deduct one copayment equal to the total number of office copayments from the global delivery payment as outlined in the benefit plan document at the time of delivery The professional services copayment is separate from any member inpatient copayment responsibilities

Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until the claim has processed so that the appropriate member responsibility can be determined Both the provider’s Statement of Account (SOA) and the Electronic Remittance Advice (ERA) will reflect the member’s responsibility amount

Services Requiring Prior Authorization

While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you will need to make sure that prior authorization has been obtained

Refer to the Authorization Policy for specific referral and authorization requirements

Preregistration is required for all obstetric admissions

Effective for dates of admission on or after January 1, 2013, preregistration for inpatient obstetric services can only be submitted within 30 calendar days prior to the admission date

Preregistrations submitted more than 30 days before the admission date for inpatient obstetric services will not be accepted and must be resubmitted within 30 days of the date of admission

Note: Preregistrations submitted more than 30 days before the admission date will not be entered into the

system

Providers should continue to complete the MHQP Obstetrical Risk Assessment Form between 12 and 14 weeks gestation and fax it to the Health Programs Department at 617-972-9417 prior to services being rendered

Obstetrical case management services are available to assist high risk members and manage antepartum care during their pregnancy When the member's obstetrician completes the MHQP Obstetrical Risk Assessment Form, the Tufts Health Plan Case Manager may enroll the member in the obstetrical case management program if applicable

In the event that the birth mother and/or the newborn(s) must stay longer due to illness, a new

preregistration is required

Some procedures require prior authorization with the Tufts Health Plan Precertification Department Refer

to the Clinical Resources section of our website for a list of procedures, services and items that require prior authorization Refer to the CareLinkSM Prior Authorization List for a list of procedures, services and items requiring prior authorization for CareLink members

For a complete description of Tufts Health Plan’s commercial authorization requirements, refer to the Authorization section of the Tufts Health Plan Commercial Provider Manual

Billing Information

• Submit the most updated industry-standard CPT and HCPCS procedure codes and modifiers

• For more information regarding modifiers refer to the Modifier Payment Policy

Note: Annually and quarterly, HIPAA medical code sets3 undergo revision by CMS, AMA and CCI Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-9 diagnosis codes As these revisions are made public, Tufts Health Plan will update its system to reflect these changes

EDI Claim Submitter Information

• Submit claims in HIPAA compliant 837P format for professional services Claims billed with non-standard codes will reject if billed electronically

Paper Claim Submitter Information

• Submit claims on a CMS-1500 form for professional services Claim line(s) billed with non-standard codes will deny

Global Obstetrical Services

When billing for global delivery, do not submit individual claims for antepartum care, as they will deny

included in the global delivery Submit only one claim following delivery for global services with the

appropriate CPT procedure code:

• 59400 (vaginal delivery)

• 59510 (Cesarean delivery)

• 59610 (vaginal delivery after a previous Cesarean delivery)

• 59618 (Cesarean delivery after vaginal delivery attempt after a previous Cesarean delivery)

Non-Global Obstetrical Services

If you do not provide global obstetrical services for various reasons including the member moving to another physician (not associated with your practice), moving away prior to delivery, losing the

pregnancy, or changing insurance plans, submit claims for non-global services with the appropriate CPT procedure codes:

• 59425-59426 (antepartum visits)

• 59409, 59514, 59612, or 59620 (delivery only)

• 59410, 59515 or 59614 (the delivery and postpartum care only)

• 59430 (postpartum care only)

Note: When billing 1–3 antepartum visits, submit the most appropriate E&M CPT procedure code Obstetrical Ultrasound

Tufts Health Plan must privilege providers who are non-radiologists and who provide imaging services within an office setting Services for which a provider is privileged are considered integral to the practice

of the provider For most instances, privileging to perform specialty appropriate procedures is granted based on a provider’s specialty designation

Accreditation by the American Institute of Ultrasound in Medicine (AIUM) is required for compensation for physicians who wish to perform and/or interpret obstetrical and gynecological ultrasounds If physicians are providing these services to their patients through a mobile imaging service, a board-certified

radiologist or AIUM-accredited physician must perform the interpretation in order to receive compensation for these services from Tufts Health Plan

For a complete list of procedure codes that are included in the Imaging and Privileging Program or for information on obtaining certification, refer to the Imaging Privileging Program chapter of the Tufts Health Plan Commercial Provider Manual or the Imaging Services Professional Payment Policy

Compensation/Reimbursement Information

Providers will be compensated based on their contractual arrangements with Tufts Health Plan regardless

of the address where the service is rendered Claims are subject to payment edits that are updated at

3 HIPAA medical code sets include HCPCS, CPT Procedure and ICD-9 diagnosis codes.

regular intervals and generally based on Centers for Medicare & Medicaid Services (CMS), specialty society guidelines, drug manufacturers’ package label inserts and National Correct Coding Initiative (CCI)

Obstetricians receive one global case payment for total obstetrical care including antepartum visits, delivery and postpartum visits Included in the global case payment are the routine urine lab tests and other related tests performed at each antepartum visit Tufts Health Plan will deduct one copayment equal

to the total number of office copayments from the global delivery payment based on the benefit plan document at the time of delivery

Antepartum and Postpartum Care

When an Obstetrician performs either antepartum or postpartum services only, Tufts Health Plan

compensates for individual visits or visit ranges when reported according to the billing guidelines

When a member transfers to an Obstetrician late in her pregnancy, Tufts Health Plan compensates for the antepartum visits, the delivery and postpartum care, when reported according to the billing guidelines E&M Services Provided Within Global Period

Surgical procedures are assigned a global day period of 0, 10 or 90 day(s) by CMS based on the

complexity of the procedure Services rendered within the assigned specified numbers of global days, including E&M services, are considered inclusive to the primary procedure and are not eligible for

separate compensation

Ultrasound Compensation

Tufts Health Plan will compensate for the following procedure codes below once during the second and third trimester unless billed with one of the high-risk ICD-9 codes below If any of the procedure codes listed below is billed more than once without a high-risk ICD-9 code, Tufts Health Plan will change the procedure code to a more appropriate procedure code, either 76815 (ultrasound, pregnant uterus, limited real time with image documentation) or 76816 (ultrasound, pregnant uterus, follow-up, transabdominal approach, per fetus)

Procedure

76805 Ultrasound, pregnant uterus, fetal and maternal evaluation after first trimester [greater

than or equal to 14 weeks 0 days], transabdominal approach; single or first gestation

76810 Ultrasound, pregnant uterus, fetal and maternal evaluation after first trimester [greater

than or equal to 14 weeks 0 days], transabdominal approach; each additional gestation

76811 Ultrasound, pregnant uterus, fetal and maternal evaluation plus detailed fetal anatomic

examination, transabdominal approach; single or first gestation

76812 Ultrasound, pregnant uterus, fetal and maternal evaluation plus detailed fetal anatomic

examination, transabdominal approach; each additional gestation

High risk

ICD-9 Code Description

640.03 Threatened abortion

632 Missed abortion

633 Suspected ectopic

630 Suspected hydatiform mole

646.83 Size/date discrepancy

657.03 Polyhydramnios

656.53 Fetal growth restriction

When procedure code 76856 (Echography, pelvic) is billed with 76831 (Saline infusion

sonohysterography, including color flow Doppler, when performed), procedure code 76856 will not be

covered

Statement of Account (SOA)

The SOA is sent to all providers to provide information on the status of the claim(s) submitted to Tufts Health Plan The SOA indicates status of claims payments, denials and pending claims

Effective January 1, 2012, paper Statements of Account and the Summary of Account on Tufts Health Plan's secure Provider website will no longer display embedded procedure code modifiers or any Tufts Health Plan unique characters

Electronic Remittance Advice (ERA)

The HIPAA compliant 835 ERA is an EDI transaction that providers may request to electronically post paid and denied claims information to their accounts receivable system

Document History

February 2008: Revised general benefit information with self-service channels information

July 2010: Revised member responsibility and reimbursement information to clarify copayment language

September 2010: Added information regarding Preventive Services

October 2011: Template updates, no content changes

February 2012: Policy reviewed, no content changes

March 2012: Updated CareLink disclaimer language

November 2012: Added change in preregistration requirements, effective for dates of admission on or after January 1, 2013,

Audit and Disclaimer Information

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all

payments related to non-compliance

This policy provides information on Tufts Health Plan claims adjudication processing guidelines As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, and adherence to plan policies and procedures and claims editing logic

This policy does not apply to Tufts Medicare Preferred HMO or the Private Health Care Systems (PHCS) network (also known as Multiplan) This policy applies to CareLink when CIGNA HealthCare is Primary Administrator for providers in Massachusetts and Rhode Island service areas Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider agreements with respect to

CareLink members