SOONERCARE Perinatal Services Provider Training 2009.
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Transcript of SOONERCARE Perinatal Services Provider Training 2009.
SOONERCARE Perinatal Services
Provider Training
2009
SoonerCare & Perinatal Services
Nearly 60% of Oklahoma births were reimbursed by SoonerCare in FY2008
Perinatal Advisory Taskforce
1 down, only 32,887 to go. . .
SoonerCare
Benefit Expansions
2006Smoking/Tobacco Use Cessation CounselingUltrasounds
2007Perinatal Dental Prenatal Risk AssessmentObstetrical High Risk Care (i.e., NSTs, BPPs)Maternal & Infant Health Social Work ServicesLactation Consultation ServicesGenetic Counseling Services
2008Soon-To-Be-Sooners
Smoking & Tobacco Use Cessation Counseling
“5 A’s” Intervention
Ask the patient to describe his/her smoking
Advise the patient to quit
Assess the willingness of the patient to quit
Assist with referrals and plans to quit
Arrange for follow-up
Smoking/Tobacco Use Cessation Counseling--Provider Types
Physicians
Physician assistants
Nurse Practitioners
Nurse Midwives
OSDH & FQHC nursing staff
Dentists
Smoking/Tobacco Use Cessation Counseling
Paid in addition to other appropriate services rendered on the same dayUp to 8 sessions/year per individual with documented tobacco useCoverage for SoonerCare, STBS and Insure Oklahoma IP
99406—3-10 minute session 99407—More than 10 minutesNo billing for less than 3 minutes
Smoking/Tobacco Use Cessation Counseling Documentation
OHCA 5 A’s Tobacco Cessation Counseling Documentation Form (CH-18)
Chart documentation must include:
A separate note
Separate signature
Patient specific information addressed in the 5 A’s
Time spent by the practitioner performing the counseling
Smoking & Tobacco Use Cessation Additional Support
MedicationsZyban
Chantix
Nicotine Replacement Products Nicotine patches
Nicotine gum
Oklahoma Tobacco Helpline
Perinatal Dental
Limited dental benefits for members who are pregnant &/or up to 60 days postpartum
No referral or PA requiredExams
Radiography
Cleanings (including scaling and planing)
Fillings
Extractions
Smoking & Tobacco Use Cessation Counseling
Prenatal Risk Assessment
Separate payment for initial assessment of pregnant member Must complete both:
1. American College of Obstetricians and Gynecologists (ACOG) Assessment Form
2. OHCA Prenatal Psychosocial Assessment Form (CH-16)(English & Spanish versions)
Prenatal Risk AssessmentCodes/Limits
HCPC code H1000
Limits:Two assessments per pregnancy
(i.e., member changes providers during pregnancy)
One assessment per provider
OB Ultrasound Coverage
Three categories:
1. All Pregnant Members
2. Pregnant members with suspected or identified fetal anomalies/maternal conditions
3. Pregnant members with confirmed High Risk OB (approved High Risk OB PA)
OB Ultrasounds All Pregnant Members:
One First-Trimester (abdominal or transvaginal)CPT codes 76801/76817
-----------AND--------------One Second- or Third-Trimester
CPT code 76805
Performed by:OB/GYNRadiologistMFMNurse MidwifeFamily Practice PhysicianAdvanced Practice Nurse Practitioner in OB, certified in OB Ultrasonography
OB UltrasoundsPregnant members with suspected or identified
fetal anomalies/maternal conditions Assessment to confirm, performed by MFM
One fetal/maternal evaluation with detailed fetal anatomic exam (“Level II”)
CPT codes 76811/76812
Follow-upCPT code 76816 or 76817
Up to 6 medically indicated follow-ups (additional require PA )
OB UltrasoundsPregnant members with confirmed High Risk OB (approved High Risk OB PA)
Additional ultrasounds allowed for pregnant members with approved high risk obstetrical conditions
Requires High Risk OB Prior Authorization
See HROB slides (Referral and confirmation of approved maternal/fetal condition by MFM and approved OHCA CH-17)
High Risk OB Care (HROB)
Limited set of additional pregnancy care services for certain high risk maternal/fetal conditions (prior authorization required)
Enhanced Antepartum Management
Fetal Nonstress Tests
Biophysical Profiles
Additional Ultrasounds
Automatic referral for SoonerCare Care Management
HROB ProcessHigh Risk OB services require PA
PA approval process begins with MFM consult
MFM services allowed without PA (for high risk confirmation):
One fetal/maternal evaluation with detailed fetal anatomic exam (“Level II”)
Up to 6 medically indicated follow-ups (additional follow-ups require PA )
One NST or one BPP
Primary OB and MFM are encouraged to co-manage care when appropriate
HROB-- Enhanced Antepartum Management
Additional reimbursement to primary OB provider for management of approved high risk OB patients ($20/ antepartum care visit)
Exception: Not available for state-employed providers
HROB Prior Authorization required Paid in addition to E&M &/or global feesCode H1001
HROB-- Tests/Procedures NOTE: Prior authorization requiredAdditional Ultrasounds
Combined limit of 6CPT Codes 76815, 76816, 76817
Fetal Nonstress Tests and Biophysical ProfilesFetal Nonstress Tests (NST)
CPT Code 59025Biophysical Profiles (BPP)
CPT Code 76818 (with non-stress testing) CPT Code 76819 (without non-stress testing)
59025 + 76818 + 76819 limited to combined total of twelve (12) units
Required HROB PA Forms
1. Comprehensive assessment by MFM (signed by MFM with treatment recommendations)
2. Chart notes documenting high risk condition
3. CH-17 High Risk OB Treatment Plan/ Prior Authorization Request signed by MFM (primary OB signature only required when requesting enhanced antepartum management fee-H1001)
4. HCA 13-A Cover Sheet
Fax: 405-702-9080 or 866-574-4991
Maternal & Infant Health Social Work Services
Licensed Clinical Social Workers (LCSW) with training and experience in Maternal & Infant Health Services for pregnant women with psychosocial factors/conditions that may lead to poor pregnancy &/or infant health outcomes
Domestic violenceSubstance abuseLack of basic resourcesMental IllnessOther psychosocial concerns
Maternal & Infant Health Social Work Services
Consider methods to refer or incorporate use of LCSW services in OB practice (LCSW contracts directly with OHCA)No formal referral required
Individual may self-refer May be referred by OB or other provider
Services are covered:During pregnancyUp to 60 days postpartum
Listing of SoonerCare contracted providers at www.okhca.org
Lactation Consultant Services
Individualized care to address specific breastfeeding issues &/or manage lactation crisisFamiliarize and encourage members about this serviceCovered during pregnancy & up to 60 days postpartum No formal referral required
Lactation Consultant Services
Eligible ProvidersMust have both:
1) Be either a Licensed Nurse or Licensed, Registered
Dietitian--and--2) Be an International Board
Certified Lactation Consultant, Registered
Lactation Consultant (IBCLC, RLC)
Must have a current OHCA contract
Listing of SoonerCare contracted providers at www.okhca.org
Genetic Counseling
Services for pregnant/postpartum SoonerCare members facing potential or diagnosed birth defectsServices provided by Licensed or Board Certified Genetic CounselorsReferred by OB or pediatric provider (usually by specialist)
Soon-To-Be-Sooners (STBS)
Coverage of pregnancy related services for undocumented or non-citizen pregnant women residing in Oklahoma
Soon-To-Be-Sooners (STBS)
EnrollmentPregnant women apply using regular SoonerCare application (SC-1)STBS members receive a member ID card and a welcome letter explaining the program and covered services
NOTE: Pregnant women must be enrolled in STBS for reimbursement of non-emergency services
STBS Covered ServicesOffice visits related to the baby (antepartum care) including usual covered labs and ultrasounds Two office visits per month (outside of global antepartum care visits) for conditions that impact the pregnancy--i.e., specialists, lactation consultant, social workerHigh Risk OB services as medically necessary (prior authorization required)
Services must be for the benefit of the unborn child (optimize pregnancy outcome)
STBS Covered Services
Maternal and Infant Health Social Work Services
Lactation Consultation Services
Genetic Counseling
Hospital services for the delivery
Patient advice line
Pharmaceuticals related to optimizing pregnancy outcome
STBS Excluded Services
Services not covered for STBS:Dental services SoonerRide (transportation)Vision ServicesServices for conditions that do not impact pregnancy outcomeServices for the mother after delivery
No coverage for family planning products or tubal ligation
STBS Pharmacy Coverage
Prescriptions are covered for pregnancy related conditions as medically necessary
Most STBS prescriptions require pharmacy PA (OHCA internal process—24 hour turn around)
No pharmacy PA required for prenatal vitamins or Macrobid; (more coming soon)
Many prescription medications are covered for STBS members!
STBS Pharmacy PA Process
Provider writes prescription as usual; calls in or sends Rx with member to local pharmacy
Provider may send OHCA form “Pharm-4” with prescription to expedite pharmacy PA process—list diagnosis and reason why medically necessary for pregnancy
If no form sent, pharmacy will fax form to provider for completion
PA usually processed within 24 hours
STBS Claims Processing
All STBS claims, other than global deliveries, are medically reviewed to ensure claim meets medically necessary criteria to benefit the fetus/optimize pregnancy outcome.Claims payment will take a minimum of 30 daysProviders must submit documentation with claim
HCA-13 Electronic Paper Attachment Cover Sheet
Oklahoma Health Care AuthorityElectronic Claim Paper Attachment Form
Cover Sheet
100123456A
STBS Deliveries & Reimbursement
STBS alien global deliveries (antepartum & delivery) have a two stage reimbursement process
1st--Payment is made on delivery portion only2nd--Payment is made on remainder of global (antepartum care portion)
Paid on a monthly cycle
Newborn Arrival (after STBS)
Newborns of mothers covered under STBS are U.S. citizens and are eligible for full scope SoonerCare benefits
Newborns receive up to 12 months SoonerCare eligibility
Newborns are added by OKDHS caseworker or electronic NB-1 process at hospital
OHCA Perinatal Contacts
Shelly Patterson Perinatal Coordinator
Terrie FritzDirector of Child Health [email protected]
OHCA Child Health Unit405-522-7188
The End!