PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Hysterorrhaphy of ruptured uterus
How to Submit
N/A - No authorization is required
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
External cephalic version, with or without tocolysis
How to Submit
N/A - No authorization is required
Delivery of placenta (separate procedure)
How to Submit
N/A - No authorization is required
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-5 Obstetrical Services
Obstetrical Services are antepartum care, labor and delivery, and postpartum care. Standards of care are published by the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control (CDC), and the American College of Nurse Midwifery (ACNM) for the perinatal care of the pregnant beneficiary.
Limits
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the attending provider is covered only through the paper adjustment process.
The following limitations apply to obstetric care services:
- a. Labor Antepartum care package services are covered once during the beneficiary’s
pregnancy. In special circumstances (such as when the pregnant beneficiary moves), up to three different providers may bill for antepartum care 4–6 visits. This does not apply to different providers in the same group.
- b. Postpartum health care coverage will extend through the end of the month in which
the 12-month post-pregnancy period ends.
- c. Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited
to two hours per day.
- d. Performance of an episiotomy or delivery of a placenta by a provider other than the
attending provider is covered only through the paper adjustment process.
Exclusions
Specific Criteria Not Covered by Medicaid Duplications of OB services;
Home pregnancy tests;
Ultrasounds performed only for determination of gender of fetus or to provide a keepsake picture;
Paternity testing;
Parenting classes;
Home tocolytic infusion therapy; and More than 3 pregnancy risk screenings per pregnancy. a. Medicaid shall not cover specific antepartum and postpartum services for any individual without state coverage who are only eligible for emergency services.
Sterilization procedures are not defined as emergency services and therefore shall not be covered for undocumented aliens.
Specific procedures are covered only in an emergency, such as an ectopic pregnancy. Stand-by Services Medicaid shall not cover stand-by services for pre-anesthesia evaluations.b. Medicaid shall not cover stand-by services for the beneficiary and for the newborn when provided by the same provider.
Place of Service
Inpatient hospital, Outpatient hospital, Office, Birthing Center
How to Submit
N/A - No authorization is required
Resources
1E-2 Therapeutic and Non-therapeutic Abortions
Therapeutic Abortion A therapeutic abortion is the termination of a pregnancy where fetal heart tones are present at the time of the abortive procedure. The termination of a pregnancy may be induced medically (prostaglandin suppositories, etc.) or surgically (dilation and curettage, etc.). This includes the delivery of a non-viable (incapable of living outside the uterus) but live fetus, if labor was augmented by pitocin drip, laminaria suppository, etc.
Non-Therapeutic Abortion A non-therapeutic abortion is any termination of a pregnancy where there has been no manual or surgical interruption of that pregnancy (missed, incomplete, spontaneous, etc.).
Limits
A non-therapeutic abortion is defined as termination of a pregnancy where there has been no manual or surgical interruption of the pregnancy, such as missed, incomplete, or spontaneous abortion. Medicaid covers non-therapeutic abortions when the procedure is medically necessary and provided in accordance with federal and state laws and regulations. Specific coverage for non-therapeutic abortion applies when the termination of pregnancy occurs without any manual or surgical interruption of that pregnancy, including missed, incomplete, and spontaneous abortions.
Place of Service
Inpatient, Outpatient Hospital, Office
How to Submit
N/A - No authorization is required
Resources
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