Notification



Notification Issue Date:



Claim Payment Policy


Title:Direct Access to Obstetrics/Gynecology (OB/GYN) Services

Policy #:00.09.01f


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

The Company's health maintenance organization (HMO) and HMO point of service (POS) products allow individuals to obtain obstetrical/gynecological (OB/GYN) services without a referral from their primary care provider. In such cases, these services must be performed by one of the eligible OB/GYN providers or primary care providers certified in family planning listed below:

  • Obstetrician
  • Gynecologist, including urogynecologist
  • Obstetrician-gynecologist
  • Gynecologic oncologist
  • Reproductive endocrinologist
  • Infertility specialist
  • Maternal fetal medicine specialist
  • Perinatologist
  • Midwife
  • Primary care provider certified in family planning

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, covered services that include, but are not limited to, preventive care, care for problem related obstetric/gynecologic (OB/GYN) conditions, and routine OB/GYN care performed by eligible providers, are covered under the medical benefits of the Company's products.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

Individuals with a health maintenance organization (HMO) or HMO point of service (POS) product may obtain covered services from a network OB/GYN or other specified provider (as listed in the Policy section) without a referral.
References

Commonwealth of Pennsylvania (PA). PA Code 28, Chapter 9: Managed care organizations, 9.682: Direct access for obstetrical and gynecological care. [PA Code Web site]. 01/01/99. Available at: http://www.pacode.com/secure/data/028/chapter9/s9.682.html. Accessed May 8, 2019.


Commonwealth of Pennsylvania (PA). PA Code 28, Chapter 9: Managed care organizations, 9.683: Standing referrals or specialists as primary care providers. [PA Code Web site]. 01/01/99. Available at: http://www.pacode.com/secure/data/028/chapter9/s9.683.html. Accessed May 8, 2019.

Company Benefit Contracts

Company Provider Manuals



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Report the CPT code(s) that correspond(s) to the service(s) provided.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A




Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Report the HCPCS code(s) that correspond(s) to the service(s) provided.


Revenue Code Number(s)

N/A


Misc Code

N/A:

N/A



Coding and Billing Requirements


Cross References


Policy History

REVISIONS FROM 00.09.01f:
10/07/2019This version of the policy will become effective 10/07/2019.

This policy has been updated to include provisions wherein individuals with health maintenance organization (HMO) and HMO point of service (POS) products may obtain obstetrics/gynecology (OB/GYN) services from primary care providers who are certified in family planning without a referral.
Version Effective Date: 10/07/2019
Version Issued Date: 10/07/2019
Version Reissued Date: N/A



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