Obstetrics/Gynecology Professional Payment Policy doc

Originated 12/2002, Revised 11/2012 1 of 5 Tufts Health Plan — Obstetrics/Gynecology Payment Policy
2099121

The following payment policy applies to Tufts Health Plan commercial contracted providers who render
obstetrical and/or gynecological services. This policy applies to commercial
1
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.

General Benefit Information
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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.

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Commercial products include HMO, POS, PPO & CareLink
SM
when Tufts Health Plan is Primary Administrator
2
Eligibility is subject to retroactive reporting of disenrollment.

Obstetrics/Gynecology
Professional Payment Policy



Originated 12/2002, Revised 11/2012 2 of 5 Tufts Health Plan – Obstetrics/Gynecology 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
.

Authorization Requirements.
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 CareLink
SM
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
.



Originated 12/2002, Revised 11/2012 3 of 5 Tufts Health Plan – Obstetrics/Gynecology Payment Policy

Note: Annually and quarterly, HIPAA medical code sets
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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

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


Originated 12/2002, Revised 11/2012 4 of 5 Tufts Health Plan – Obstetrics/Gynecology Payment Policy

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
Code
Description
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.


Originated 12/2002, Revised 11/2012 5 of 5 Tufts Health Plan – Obstetrics/Gynecology Payment Policy

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.