Medicare Advantage

Medical Policy

Notification

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

Notification Issued Date:

This 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.

Title:

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

Policy #:

MA00.032h

Policy

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 Health Maintenance Organization Point-of-Service (HMO-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 a provider specialized in one of the following:

Obstetrics
Gynecology, including urogynecology
Gynecologic oncology
Reproductive endocrinology
Infertility
Maternal fetal medicine
Perinatology
Nurse midwifery
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 Evidence of Coverage, 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.

Description

Individuals with a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-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 October 19, 2021.

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 October 19, 2021.

Company Provider Manuals.

Evidence of Coverage.

Coding

CPT Procedure Code Number(s)

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

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

1/1/2026

Version Issued Date:

1/9/2026

Version Reissued Date: