Commercial

Direct Access to Obstetrics/Gynecology (OB/GYN) Services
00.09.01h

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 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.

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 eligible providers, 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

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

Commonwealth of Pennsylvania (PA). PA Code 28, Chapter 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 May 8, 2019.

Commonwealth of Pennsylvania (PA). PA Code 28, Chapter 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 May 8, 2019.

Company Benefit Contracts

Company Provider Manuals

Coding

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

ICD - 10 Procedure Code Number(s)
N/A

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




Coding and Billing Requirements


Policy History

1/1/2021
1/4/2021
00.09.01
Claim Payment Policy Bulletin
Commercial
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No