OB/GYN Services

• General Information
• Obstetrical Needs Assessment Form
• OB/GYN Referrals
• Diagnostic Testing
• Medical Assistance Sterilization/Hysterectomy Consent Forms
• Newborns
• Universal OB Access Program Follow-up Requirements
• Coding
• Family Planning Guidelines
• Appointment Standards

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 verify eligibility of the member. Gateway members may also self-refer for family planning services.

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 early in the pregnancy and engage the woman in care management. For that reason, the Obstetrical Needs Assessment Form must be faxed to Gateway’s MOM Matters ^® Department within 2-5 business days of the intake visit. 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.

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 participating Perinatologists.

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

Fetal Non-stress Tests and Obstetrical 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.

A referral is not required for mammograms performed at a participating hospital. Only a prescription is needed.

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 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.

Under the per visit reimbursement structure, the following procedure codes should be used when billing Gateway. All prenatal visits and dates of service must be included on the CMS 1500 form and identified with Evaluation and Management code (99201 – 99215) ONLY. The U9 pricing modifier must follow the code in the first position on the claim form. Please do not use the State’s pricing or informational modifiers on any other Healthy Beginning codes for submission to Gateway. Delivery charges must be identified with CPT codes.

As of July 1, 2008 Gateway will reimburse providers a bonus payment of $200 plus your contracted percentage increase for initial prenatal visits rendered within the first trimester. Please bill as indicated below to receive the bonus payment:

The initial prenatal visit MUST be rendered within the first trimester and the Obstetrical Needs Assessment Form (ONAF) must be completed during the visit and faxed to Gateway’s MOM Matters^® department within 2-5 business days of the visit.

Procedure codes 99429-HD (First Trimester Outreach) and T1001-U9 (Initial Risk Assessment) must be reported together on the same claim form to allow the bonus payment.

The bonus payment will not be paid if both codes/modifiers referenced above are not reported on the same claim. The ONAF is not a claim form; however, the ONAF must be received by Gateway and documented in our claims system prior to receipt of the claim to allow the appropriate bonus and intake visit payment.

If the member’s first prenatal visit doesn’t occur within the first trimester then code 99429-HD should not be billed. However, the first visit with an obstetrical patient is considered to be the intake visit. 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 ONAF must be completed and a claim submitted with code T1001-U9 for reimbursement.

All family planning benefits provided under Gateway are administered and contracted for by Adagio Health. 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 for Family Planning Services only.
• 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 Adagio Health at 1-800-532-9465.

Post-partum tubal ligations must be preauthorized by Adagio Health. 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.

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

Appointment standards for OB/GYN practitioners are as follows: