Medicare Advantage

Medical Policy

Title:

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

Policy #:

MA00.032f

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 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 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 Benefit Contracts.

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

Revisions From MA00.032f:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
11/13/2023	This version of the policy will become effective 11/20/2023. The policy has been reviewed and updated to communicate the Company’s continuing position on direct access to Obstetrics/Gynecology (OB/GYN) services.

Revisions From MA00.032e:

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023.

The following CPT/HCPC codes have been removed from this policy:
99219 and 99241

The following procedure codes have undergone narrative revisions:
99221, 99231, 99232, 99233, 99235, 99236, 99242, 99243, 99244, 99245, 99252, 99253, 99254, and G2212

Revisions From MA00.032d:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.

The following procedure codes had narrative revisions:
11981 and 99211

Revisions From MA00.032c:

11/03/2021	This policy has been reissued in accordance with the Company's annual review process.
01/01/2021	This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021. The following HCPC codes were added to this policy: G2211, G2212, G2251, and G2252 Procedure code 99201 was removed from this policy. The following procedure codes had narrative revisions: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 and 99215

Revisions From MA00.032b:

10/07/2019

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.

Version Effective Date:

1/1/2024

Version Issued Date: