SOONERCARE Perinatal Services Provider Training 2009 Slide 2 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 Slide 3 Benefit Expansions 2006 Smoking/Tobacco Use Cessation Counseling Ultrasounds 2007 Perinatal Dental Prenatal Risk Assessment Obstetrical High Risk Care (i.e., NSTs, BPPs) Maternal & Infant Health Social Work Services Lactation Consultation Services Genetic Counseling Services 2008 Soon-To-Be-Sooners Slide 4 Smoking & Tobacco Use Cessation Counseling 5 As 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 Slide 5 Smoking/Tobacco Use Cessation Counseling--Provider Types Physicians Physician assistants Nurse Practitioners Nurse Midwives OSDH & FQHC nursing staff Dentists Slide 6 Smoking/Tobacco Use Cessation Counseling Paid in addition to other appropriate services rendered on the same day Up to 8 sessions/year per individual with documented tobacco use Coverage for SoonerCare, STBS and Insure Oklahoma IP 994063-10 minute session 99407More than 10 minutes No billing for less than 3 minutes Slide 7 Smoking/Tobacco Use Cessation Counseling Documentation OHCA 5 As Tobacco Cessation Counseling Documentation Form (CH-18) Chart documentation must include: A separate note Separate signature Patient specific information addressed in the 5 As Time spent by the practitioner performing the counseling Slide 8 Smoking & Tobacco Use Cessation Additional Support Medications Zyban Chantix Nicotine Replacement Products Nicotine patches Nicotine gum Oklahoma Tobacco Helpline Slide 9 Perinatal Dental Limited dental benefits for members who are pregnant &/or up to 60 days postpartum No referral or PA required Exams Radiography Cleanings (including scaling and planing) Fillings Extractions Smoking & Tobacco Use Cessation Counseling Slide 10 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) OHCA Prenatal Psychosocial Assessment (English & Spanish versions) Slide 11 Prenatal Risk Assessment Codes/Limits HCPC code H1000 Limits: Two assessments per pregnancy (i.e., member changes providers during pregnancy) One assessment per provider Slide 12 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) Slide 13 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/GYN Radiologist MFM Nurse Midwife Family Practice Physician Advanced Practice Nurse Practitioner in OB, certified in OB Ultrasonography Slide 14 OB Ultrasounds Pregnant 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-up CPT code 76816 or 76817 Up to 6 medically indicated follow-ups (additional require PA ) Slide 15 OB Ultrasounds Pregnant 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) Slide 16 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 Slide 17 HROB Process High 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 Slide 18 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 fees Code H1001 Slide 19 HROB-- Tests/Procedures NOTE: Prior authorization required Additional Ultrasounds Combined limit of 6 CPT Codes 76815, 76816, 76817 Fetal Nonstress Tests and Biophysical Profiles Fetal Nonstress Tests (NST) CPT Code 59025 Biophysical 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 Slide 20 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) CH-17 High Risk OB Treatment Plan/ Prior Authorization Request 4. HCA 13-A Cover Sheet HCA 13-A Cover Sheet Fax: 405-702-9080 or 866-574-4991 Slide 21 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 violence Substance abuse Lack of basic resources Mental Illness Other psychosocial concerns Slide 22 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 pregnancy Up to 60 days postpartum Listing of SoonerCare contracted providers at www.okhca.org Slide 23 Lactation Consultant Services Individualized care to address specific breastfeeding issues &/or manage lactation crisis Familiarize and encourage members about this service Covered during pregnancy & up to 60 days postpartum No formal referral required Slide 24 Lactation Consultant Services Eligible Providers Must 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 Slide 25 Genetic Counseling Services for pregnant/postpartum SoonerCare members facing potential or diagnosed birth defects Services provided by Licensed or Board Certified Genetic Counselors Referred by OB or pediatric provider (usually by specialist) Slide 26 Soon-To-Be-Sooners (STBS) Coverage of pregnancy related services for undocumented or non-citizen pregnant women residing in Oklahoma Slide 27 Soon-To-Be-Sooners (STBS) Enrollment Pregnant women apply using regular SoonerCare application (SC-1)(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 Slide 28 STBS Covered Services Office 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 worker High Risk OB services as medically necessary (prior authorization required) Services must be for the benefit of the unborn child (optimize pregnancy outcome) Slide 29 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 Slide 30 STBS Excluded Services Services not covered for STBS: Dental services SoonerRide (transportation) Vision Services Services for conditions that do not impact pregnancy outcome Services for the mother after delivery No coverage for family planning products or tubal ligation Slide 31 STBS Pharmacy Coverage Prescriptions are covered for pregnancy related conditions as medically necessary Most STBS prescriptions require pharmacy PA (OHCA internal process24 hour turn around) No pharmacy PA required for prenatal vitamins or Macrobid; (more coming soon) Many prescription medications are covered for STBS members! Slide 32 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 processlist 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 Slide 33 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 days Providers must submit documentation with claim HCA-13 Electronic Paper Attachment Cover Sheet Slide 34 Oklahoma Health Care Authority Electronic Claim Paper Attachment Form Cover Sheet 100123456A Slide 35 STBS Deliveries & Reimbursement STBS alien global deliveries (antepartum & delivery) have a two stage reimbursement process 1 st --Payment is made on delivery portion only 2 nd --Payment is made on remainder of global (antepartum care portion) Paid on a monthly cycle Slide 36 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 Slide 37 OHCA Perinatal Contacts Shelly Patterson Perinatal Coordinator 405-522-7332 Shelly.Patterson@okhca.org Terrie Fritz Director of Child Health 405-522-7377 Terrie.Fritz@okhca.org OHCA Child Health Unit 405-522-7188 Slide 38 The End!