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

[email protected]

Terrie FritzDirector of Child Health [email protected]

OHCA Child Health Unit405-522-7188

The End!