Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Direct Access to Obstetrics/Gynecology (OB/GYN) Services
Policy #:MA00.032b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, 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. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Coverage is subject to the terms, conditions, and limitations of the member's contract.

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 HMO point of service (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.
Policy 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 HMO point of service (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

Company Benefit Contracts

Company Provider Manuals

Evidence of Coverage


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

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


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


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


Misc Code

N/A:

N/A


Coding and Billing Requirements






Policy History

REVISIONS FROM MA00.032b:
10/07/2019This 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: 10/07/2019
Version Issued Date: 10/07/2019
Version Reissued Date: N/A