This is only a notification of the policy that will be in effect on 06/10/2009. For the current version of this policy, click the following link: 00.09.01c Direct Access Obstetrics/Gynecology (OB/GYN)
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
The Company's health maintenance organization (HMO) and point of service (POS) products allow female members to obtain Direct Access covered services without a referral when performed in any setting. In such cases, these services must be medically necessary for the individual's condition and performed by eligible Direct Access obstetrical/gynecological (OB/GYN) health care providers. Eligible Direct Access OB/GYN specialties include:
Commonwealth of Pennsylvania (PA). PA Code 28, Ch 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 June 15, 2015.
Commonwealth of Pennsylvania (PA). PA Code 28, Ch 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 June 15, 2015.
Company Benefit Contracts.
United States Government Printing Office. Electronic code of federal regulations (e-CFR). §422.112: Access to services, (3) Specialty care. [e-CFR Web site]. Original: 10/1/2002 (Revised: 2/12/2015). Available at:http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=de31118366e239d4a58697b9df66bb77;rgn=div6;view=text;node=42%3A188.8.131.52.9.3;idno=42;cc=ecfr. Accessed June 15, 2015.
Policy: 11.06.02i:Elective Abortion