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.
Benitz WE; Committee on Fetus and Newborn, American Academy of Pediatrics. Hospital Stay for Healthy Term Newborn Infants. Pediatrics. 2015;135(5):948-53. Available at: http://pediatrics.aappublications.org/content/pediatrics/early/2015/04/21/peds.2015-0699.full.pdf. Accessed October 4, 2019.
Company Benefit Contracts.
Company Provider Manuals.
General Assembly of the Commonwealth of Pennsylvania. Health Security Act. Jul. 2, 1996, P.L. 514, No. 85. Available at: http://www.legis.state.pa.us/WU01/LI/LI/US/HTM/1996/0/0085..HTM. Accessed October 4, 2019.
Newborns' and Mothers' Health Protection Act, 1996. Title 42, Chapter 6A.
NJ Rev Stat § 17B:26-2.1k (2017) as amended by Public Law 1995, c. 138, s. 1. Coverage of birth and natal care; hospital insurance policy.
NJ Stat Ann § 17:48-6l. as amended by Public Law 1995, c. 138, s. 4. Coverage of birth and natal care; hospital service corporation.
Pennsylvania Health Care Cost Containment Council (PHC4). Minimum maternity stay legislation: Changes in hospital length-of-stay for child birth. [PHC4 Web site]. October 1999. Available at: http://www.phc4.org/reports/cdlos/docs/reportCdlos1999.pdf. Accessed October 4, 2019.
US General Accounting Office Health, Education, and Human Services Division. Maternity Care: Appropriate Follow up Services Critical with Shorter Hospital Stays. September 1996. Available at: http://www.gpo.gov/fdsys/pkg/GAOREPORTS-HEHS-96-207/pdf/GAOREPORTS-HEHS-96-207.pdf. Accessed May 29, 2019.
O82 Encounter for Cesarean delivery without indication
Z39.2 Encounter for routine postpartum follow-up