OB/GYN Services

General Information To eliminate any perceived barrier to accessing OB/GYN services, Gateway allows all female members to self-refer to any participating OB/GYN for any OB/GYN related condition, not just for an annual exam or suspected pregnancy. When a member self-refers to the OB/GYN, the OB/GYN's office is required to contact Gateway to verify eligibility of the member. Gateway members may also self-refer for family planning services. Gateway permits its primary care practitioners to perform routine gynecological exams and pap tests and provide care during pregnancy if they are so trained and equipped in their office. Primary care practitioners who provide obstetrical services must bill in accordance with the Gateway guidelines and may only provide obstetrical services to those patients assigned to their panel.

Obstetrical Needs Assessment Form The first visit with an obstetrical patient is considered to be the intake visit, or if a patient becomes a Gateway member during the course of her pregnancy, her first visit as a Gateway member is considered to be her intake visit. At the intake visit, an Obstetrical Needs Assessment Form , found in the Forms and Reference Material Section of this Manual, must be completed.

The Obstetrical Needs Assessment Form should immediately be faxed to Gateway and then filed in the member's medical record. The Obstetrical Needs Assessment Form should be updated at the 28-32 week visits and also at the post-partum visit. These two updates should also be faxed to Gateway immediately following completion.

The purpose of the Obstetrical Needs Assessment Form is to help identify risk factors before delivery. For that reason, the Obstetrical Needs Assessment Form must be faxed to Gateway's MOM Matters^® Department within 30 days of the intake visit and at least 30 days prior to delivery. The Obstetrical Needs Assessment Form is not a claim. However, the Obstetrical Needs Assessment Form must be received by Gateway in order to process the claim for the intake visit. Please submit claims on a CMS-1500 within 180 days to receive payment for the intake package.

OB/GYN Referrals When a patient is referred outside of the OB/GYN office to another specialist, a referral from the member's primary care practitioner is required. The OB/GYN practitioner is responsible for providing written correspondence to the member's primary care practitioner for coordination and continuity of care.

If an OB/GYN determines that assessment or treatment by another specialty care practitioner is necessary, the OB/GYN is required to contact the member's primary care practitioner to request a referral to a specialist. The OB/GYN cannot refer a member directly to another specialty care practitioner with the exception of Perinatologists.

Refer to the Referral and Authorization Section of this Manual for additional information regarding the OB/GYN Referral.

Diagnostic Testing Fetal Non-stress Tests and Ultrasounds can be performed in the OB/GYN's office or at a hospital without an authorization or a referral from Gateway.

All other testing or procedures related to OB/GYN services requiring the member to use a hospital can be approved via the OB/GYN referral.

Rhogam does not require a referral from the primary care practitioner or an authorization from Gateway. Rhogam should be billed with code J2790 and with code 90384 for the administration of the drug. A referral is not required for mammograms performed at a participating hospital. Only a prescription is needed.

Medical Assistance Sterilization/Hysterectomy Consent Forms The Department of Public Welfare requires that Gateway members sign a Medical Assistance Sterilization Consent Form (MA-30), or a Patient Acknowledgement Form (MA-31), thirty (30) days prior to the procedure for Hysterectomies when receiving these services. Copies of these forms can be found in the Forms and Reference Materials Section of this Manual.

Newborns Newborns of Gateway mothers will be covered by Gateway for services rendered during the neonatal period. The Department of Public Welfare requires that the hospital submit the MA-112 Form for each newborn to the mother's assigned County Assistance Office. All charges for newborns that become enrolled in the plan, other than hospital bills covering the confinement for both mom and baby, are processed under the newborn name and newborn Gateway Identification Number.

Universal OB Access Program Follow-up Requirements

Item	OB Referral?	Authorization?	Type of PCP Follow-up
IN OFFICE SERVICES
Annual Gynecological Exam	No	No	Summary Report
Other Related Gynecological Services	No	No	Summary Report
Suspected Pregnancy	No	No	None
Initial Intake	No	No	OB Risk Assessment Form
Prenatal Visits	No	No	None
Identification of New Risk Factors	No	No	Updated Risk Assessment
Other Related OB Services	No	No	None
Prenatal Support Services	No	No	None
Family Planning Services	No	No	None
Fetal Non Stress Test	No	No	None
OUT OF OFFICE SERVICES
SPU/Ambulatory Surgery Services*	No	Yes	Summary Report
Inpatient Hospitalization	No	Yes	Summary Report
Home Healthcare/Hospice Services/ IV Infusion	No	Yes	None
Mammogram	No	No	Summary Report
Ultrasound	No	No	None
Fetal Non Stress Test	No	No	None
STAT Laboratory Services* *	No	No	None
Other Outpatient Diagnostic Tests	Yes	No	Summary Report
Prenatal Support Services	Yes	No	None
Delivery and Discharge Services	No	No	Summary Report

*These services can be authorized by calling Gateway's Utilization Management Department at 1-800-392-1146. Home Health visits should be offered to all newborns.

**A referral is required only if the hospital is not the member's designated lab. If you are unsure of the hospital's laboratory status, please call Provider Servicing at 1-800-392-1145.

Please refer to the Family Planning and Obstetrical Needs Quick Reference Guide

Coding PLEASE NOTE DATA SUBJECT TO CHANGE IN ORDER TO COMPLY WITH HIPAA REGULATIONS. Gateway will notify practitioners of changing policies via an update mailing or the provider newsletter, The Gateway Review.

Under the per visit reimbursement structure, the following procedure codes should be used when billing Gateway. Please remember to submit a claim form for each visit.

Description	Code	Description	Code
Initial Assessment	W5950	1^st Trimester Normal	W5975
1^st Trimester High Risk	W5976	2^nd Trimester Normal	W5977
2^nd Trimester High Risk	W5978	3^rd Trimester Post Partum Normal	W5979 W5979-In addition to the appropriate diagnosis code; such as V24.1, V24.2, V72.3 or V76.2 as the diagnosis
3^rd Trimester Post Partum High Risk	W5980 W5980-In addition to the appropriate diagnosis code; such as V24.1, V24.2, V72.3 or V76.2 as the diagnosis	C-section Delivery	59514
C-section Delivery with Post Partum	59515	Vaginal Delivery	59409
Vaginal Delivery with Post Partum	59410	Vaginal Delivery	59409
Other Maternity Services
Fetal Non-stress Test	59025	Fetal Biophysical Profile (Global Fee)	76818
Comprehensive Childbirth Preparation	W5957	Childbirth Preparation Review	W5958
Outreach Bonuses for 1^st Trimester Recruit	W5961	Nutritional Counseling	W5962
Smoking Cessation Counseling	W5963	Substance Abuse Problem ID and Referral	W5964
Genetic Risk Assessment	W5965	Parenting Program	W5967
Outreach Visit (maximum of 3 per pregnancy)	W5968	Urgent Transport (car)	W5969
In-depth Psycho-social Counseling	W5970	Prenatal Exercise Series	W5973
Urgent Transport (Public Carrier)	W5981	Mileage Additional Allowance	W5982

Please refer to the Family Planning and Obstetrical Needs Quick Reference Guide

Family Planning Guidelines All family planning benefits provided under Gateway are administered and contracted for by Family Health Council. If a Gateway patient presents for family planning benefits, practitioners need to be aware of the following:

The patient's Gateway eligibility can be verified by calling 1-800-642-3515.
Family planning patients DO NOT need a referral from their primary care practitioner under federal mandate. If a family planning patient becomes pregnant, she may self-refer to her OB/GYN for prenatal care. The Department of Public Welfare permits members to see any participating or non-participating practitioner.
The Sterilization Consent Form (MA-31) must be obtained from the patient thirty (30) days prior to the procedure.
The appropriate documentation must be PREAUTHORIZED at least five (5) business days prior to the procedure by calling Family Health Council at 1-800-532-9465.

Post-partum tubal ligations must be preauthorized by Family Health Council. All outpatient laboratory testing should be ordered with a prescription through the member's primary care practitioner or OB/GYN practitioner according to the primary care practitioner's designated laboratory.

Depo-Provera may be administered by Gateway practitioners and billed to Gateway. The following codes should be used when billing for Depo-Provera: J1055-150 mg drug; Z9985-injection of the drug; and W6003-annual Depo-Provera visit. Subsequent visits should be billed with an Evaluation and Management code or family planning clinic visit code. A supply of Depo-Provera can be obtained through MedMark Specialized Pharmacy Services at 1-888-347-3416. MedMark will bill Gateway directly for the supply of Depo-Provera.

Reversals of tubal ligations, vasectomies and infertility treatments ARE NOT covered by Gateway.

If a Gateway practitioner is interested in contracting with Family Health Council to provide family planning services to Gateway members, the practitioner should contact the Gateway Network Development Department at 1-800-392-1145 for further information. All family planning services are to be billed directly to Gateway.

Appointment Standards Appointment standards for OB/GYN practitioners are as follows:

First Trimester	Within 10 business days of the member being identified as being pregnant
Second Trimester	Within 5 business days of the member being identified as being pregnant
Third Trimester	Within 4 business days of the member being identified as being pregnant
High-Risk Pregnancies	Within twenty-four 24 hours of identification of high-risk by Gateway or the maternity care provider, or immediately if an emergency exits

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Last Updated: 1/1/2010