Department of Origin: Integrated Healthcare Services Approved by: Chief Medical Officer Date Approved: 12/30/14 Department(s) Affected: Coding, Claims, Customer Service, Integrated Healthcare Services Effective Date: 12/30/14 Medical Policy Document: Prenatal Testing Replaces Effective Policy Dated: 06/25/14 Reference #: MP/P011 Page 1 of 7 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Insurance Company (PIC) Group PreferredOne Insurance Company (PIC) Individual Please refer to the member’s benefit document for specific information. To the extent there is any inconsistency between this policy and the terms of the member’s benefit plan or certificate of coverage, the terms of the member’s benefit plan document will govern. Benefits must be available for healthcare services. Healthcare services must be ordered by a physician, physician assistant, or nurse practitioner. Healthcare services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. This policy applies to PAS members only when the employer group has elected to provide benefits for the service/procedure/device. Check benefits in SPD/COC. If benefits are not specifically addressed in the SPD/COC, verify with the appropriate account manager the availability of benefits. PURPOSE: The intent of this policy is to provide coverage guidelines for prenatal testing. POLICY: Prenatal testing during pregnancy is covered when the test results will influence the course or care of the member’s pregnancy and the testing is considered medically necessary. GUIDELINES: I. Routine prenatal screening lab tests – any of the following: A-O A. Blood Type (ABO)/ D Type (RH)/Antibody Screen B. Chlamydia C. Cystic Fibrosis (CF) carrier testing (standard CF transmembrane regulator [CFTR] mutation panel -CPT 81220) D. Glucose/ Glucose Tolerance Test (GTT) E. Gonorrhea F. Group B Streptococcus G. Hemoglobin/Hematocrit/MCV H. Hepatitis B (HBsAG) I. HIV J. Pap Test K. PPD L. VDRL M. Rubella Titer N. Urinalysis/Urine Culture O. Varicella Titer
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Benefits must be available for healthcare services ... in accordance with the American Congress of Obstetricians and Gynecologists (ACOG) Clinical Guideline on Antepartum Fetal Surveillance.
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Department of Origin: Integrated Healthcare Services
PreferredOne Community Health Plan (“PCHP”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
PCHP:Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages
If you need these services, contact a Grievance Specialist.
If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Grievance SpecialistPreferredOne Community Health PlanPO Box 59052Minneapolis, MN 55459-0052Phone: 1.800.940.5049 (TTY: 763.847.4013)Fax: [email protected]
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
PreferredOne Community Health Plan Nondiscrimination Notice
Language Assistance Services
NDR PCHP LV (10/16)
PreferredOne Insurance Company (“PIC”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
PIC:Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages
If you need these services, contact a Grievance Specialist.
If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
PreferredOne Insurance Company Nondiscrimination Notice