Notification

Direct Access Obstetrics/Gynecology (OB/GYN)


Notification Issue Date: 05/11/2009

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)



Claim Payment Policy


Title:Direct Access Obstetrics/Gynecology (OB/GYN)

Policy #:00.09.01e

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

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.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

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:

  • Gynecology (GYN) (including urogynecology)
  • Gynecologic oncology
  • Maternal fetal medicine/perinatology
  • Midwifery
  • Obstetrics (OB)
  • Obstetrics/gynecology (OB/GYN)
  • Reproductive endocrinology/infertility

Female members may obtain care from eligible Direct Access OB/GYN health care provider types for covered services that include, but are not limited to, preventive care and routine OB/GYN care (e.g., breast exams, mammograms, papanicolaou [PAP] tests, pelvic exams), or problem-related OB/GYN conditions.

Services not requiring referrals from primary care providers (PCPs) or OB/GYN providers include, but are not limited to, the following:
  • All antenatal screening and testing
  • Fetal or maternal imaging
  • Hysterosalpingogram/sonohysterogram

In accordance with the HMO product rules, precertification may be required for services, such as, but not limited to, the following:
  • Pelvic ultrasounds
  • Abdominal X-rays
  • Intravenous pyelograms (IVP) DXA scans

NOTE: These tests should be performed at the member’s designated radiology site.

Services, including initial consultations for HMO members and visits beyond the initial consultation, requiring referrals from PCPs or OB/GYN providers include, but are not limited to, the following:
  • Endocrinology
  • General surgery
  • Genetics
  • Gastrointestinal
  • Urology
  • Pediatric cardiology
  • Fetal cardiovascular studies

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, therapies, and 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, 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 Direct Access--eligible provider specialties, are covered under the medical benefits of the Company's products.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.
Description

Direct Access obstetrics/gynecology (OB/GYN) is a health maintenance organization (HMO) and HMO point of service (POS) benefit. This benefit allows all female members of these products to obtain covered services from a network OB/GYN or other specified provider (as listed in the Policy section) without a referral. This benefit applies to OB/GYN services obtained in any setting, in products that require a referral.

This policy applies only to HMO and HMO POS products of the Company.

There are no referral requirements for preferred provider organization (PPO) products of the Company.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4: Benefits and beneficiary protections. 120.2: Access and availability rules for coordinated care plans. [CMS Web site]. Original: 06/06/03. (Revised: 1/16/2015). Available at: http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf. Accessed June 15, 2015.


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%3A3.0.1.1.9.3;idno=42;cc=ecfr. Accessed June 15, 2015.




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)

Report the ICD-10 code(s) that correspond(s) to the service(s) provided.


HCPCS Level II Code Number(s)

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


Revenue Code Number(s)

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

Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 09/09/2015
Version Issued Date: 09/09/2015
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.