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Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook
Table of Contents
1. General Information GN-7
2. Certified Nurse Midwives GN-7
2.1 Provider Enrollment GN-7
2.2 Services/Benefits, Limitations, and Prior Authorization GN-8
2.2.1 Deliveries GN-8
2.2.2 Newborn Services GN-8
2.2.2.1 Hearing Screening GN-9
2.2.2.2 Services Provided in a Birthing Center GN-9
2.2.2.3 Antepartum & Postpartum Services GN-9
2.2.3 Prior Authorization GN-10
2.3 Documentation Requirements GN-10
2.4 Claims Filing and Reimbursement GN-10
3. Medicaid Title XIX family planning services GN-11
3.1 Title XIX Provider Enrollment GN-11
3.2 Family Planning Overview GN-12
3.2.1 Guidelines for Family Planning Providers GN-12
3.2.2 Family Planning Services for Undocumented Aliens, Legalized Aliens GN-13
3.3 Services/Benefits, Limitations, and Prior Authorization GN-13
3.3.1 Family Planning Annual Exams GN-14
3.3.1.1 FQHC Reimbursement for Family Planning Annual Exams GN-15
3.3.2 Other Family Planning Office or Outpatient Visits GN-15
3.3.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits GN-16
3.3.3 Laboratory Procedures GN-16
3.3.3.1 CLIA Requirement GN-16
3.3.3.2 Medical Record Documentation GN-16
3.3.3.3 Lab Specimen Handling and Testing GN-16
3.3.3.4 Providing Information to the Reference Laboratory GN-17
3.3.4 Radiology Services GN-17
3.3.5 Contraceptive Devices and Related Procedures GN-17
3.3.5.1 External Contraceptives GN-17
3.3.5.2 Intrauterine Device (IUD) GN-17
3.3.5.2.1 Insertion of the IUD GN-17
3.3.5.2.2 Removal of the IUD GN-18
3.3.5.3 Contraceptive Capsules GN-18
3.3.5.4 Occlusive Sterilization Device GN-18
3.3.6 Drugs and Supplies GN-18
3.3.6.1 Prescriptions and Dispensing Medication GN-18
3.3.6.2 Injection Administration GN-19
3.3.7 Medical Counseling and Education GN-19
3.3.8 Sterilization and Sterilization-Related Procedures GN-19
3.3.8.1 Sterilization Consent GN-19
3.3.8.2 Anesthesia for Sterilization GN-19
3.3.8.3 Tubal Ligation GN-19
3.3.8.4 Vasectomy GN-19
3.3.8.5 Facility Fees for Sterilization GN-20
3.3.9 Prior Authorization GN-20
3.4 Documentation Requirements GN-20
3.5 Claims Filing and Reimbursement GN-20
3.5.1 Claims Information GN-20
3.5.1.1 Family Planning and Third Party Resource GN-21
3.5.1.2 Claims Filing For Title X-Supported Clinics GN-22
3.5.2 Billing Procedures for Non-Family Planning Services Provided During a Family Planning Visit (Title XIX Only) GN-22
3.5.3 National Drug Code (NDC) GN-22
4. Women's Health Program (Title XIX Family Planning) GN-23
4.1 Women's Health Program (WHP) Provider Enrollment GN-23
4.2 WHP Overview GN-23
4.2.1 Guidelines for WHP Family Planning Providers GN-23
4.2.2 Referrals GN-24
4.2.2.1 Referrals for Breast and Cervical Cancer Screening, Diagnostics, and Treatment GN-24
4.2.2.2 Referrals for Clients Diagnosed with Breast or Cervical Cancer GN-24
4.2.3 Abortions GN-25
4.3 Services/Benefits, Limitations, and Prior Authorization GN-25
4.3.1 Family Planning Annual Exams GN-26
4.3.1.1 FQHC Reimbursement for Family Planning Annual Exams GN-26
4.3.2 Other Family Planning Office or Outpatient Visits GN-26
4.3.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits GN-28
4.3.3 Laboratory Procedures GN-28
4.3.4 Radiology GN-28
4.3.5 Contraceptive Devices and Related Procedures GN-28
4.3.6 Drugs and Supplies GN-29
4.3.6.1 Prescriptions and Dispensing Medication GN-29
4.3.7 Instruction in Natural Family Planning Methods GN-29
4.3.8 Sterilization and Sterilization-Related Procedures GN-29
4.3.8.1 Sterilization Consent GN-30
4.3.8.2 Tubal Ligation GN-30
4.3.8.3 Anesthesia for Sterilization GN-30
4.3.8.4 Facility Fees for Sterilization GN-30
4.3.8.5 Hysteroscopic Sterilization GN-30
4.3.9 Eligibility Verification GN-30
4.4 Documentation Requirements GN-31
4.5 WHP Claims Filing and Reimbursement GN-31
4.5.1 Claims Information GN-31
4.5.1.1 WHP and Third-Party Resource GN-31
4.5.2 Reimbursement GN-31
4.5.3 National Drug Code (NDC) GN-31
5. Titles V, X, and XX Family Planning Services GN-31
5.1 Provider Enrollment for Titles V, X, and XX Contractors GN-31
5.2 Family Planning Providers GN-32
5.3 Services/Benefits, Limitations and Prior Authorization GN-32
5.3.1 Titles V and XX Family Planning Annual Exams GN-32
5.3.1.1 FQHC Reimbursement for Titles V and XX Family Planning Annual Exams GN-33
5.3.2 Title V and XX Family Planning Office or Outpatient Visits GN-34
5.3.2.1 FQHC Reimbursement for Title V and XX Family Planning Office or Outpatient Visits GN-35
5.3.3 Laboratory Procedures GN-35
5.3.3.1 Title V Only GN-35
5.3.3.2 Titles V and XX GN-35
5.3.4 Radiology GN-37
5.3.5 Contraceptive Devices and Related Procedures GN-37
5.3.5.1 External Contraceptives GN-37
5.3.5.2.1 Insertion of an IUD GN-38
5.3.5.2.2 Removal of the IUD GN-38
5.3.5.3 Contraceptive Capsules GN-38
5.3.5.4 Medroxyprogesterone Acetate/Estradiol Cypionate GN-39
5.3.6 Title V and XX Drugs and Supplies GN-39
5.3.6.1 Prescriptions and Dispensing Medication GN-39
5.3.7 Family Planning Education GN-40
5.3.7.1 Medical Nutrition Therapy GN-40
5.3.7.2 Title V and XX Instruction in Natural Family Planning Methods GN-40
5.3.8 Sterilization and Sterilization-Related Procedures GN-40
5.3.8.1 Sterilization Consent GN-40
5.3.8.2 Title V and XX Incomplete Sterilizations GN-40
5.3.8.3 Titles V, X, and XX Tubal Ligation GN-41
5.3.8.4 Vasectomy GN-41
5.3.8.5 Anesthesia for Sterilization GN-41
5.3.9 Prior Authorization GN-41
5.4 Documentation Requirements GN-41
5.5 Claims Filing and Reimbursement GN-41
5.5.1 Claims Information GN-41
5.5.1.1 Filing Deadlines GN-42
5.5.1.2 Third-Party Resource GN-42
5.5.1.3 Title X Encounter Filing GN-42
5.5.2 Reimbursement GN-42
5.5.2.1 Title X Payments GN-43
5.5.3 National Drug Code (NDC) GN-43
6. Maternity Service cLinics GN-43
6.1 Provider Enrollment GN-43
6.1.1 Physician Responsibility GN-43
6.1.2 Case Management Services to High-Risk Individuals GN-43
6.2 Services, Benefits, Limitations, and Prior Authorization GN-44
6.2.1 Initial Antepartum Care Visit Components GN-44
6.2.1.2 Physical Examination GN-45
6.2.1.3 Laboratory Tests GN-45
6.2.1.4 Assessment GN-45
6.2.1.6 Education and Counseling GN-46
6.2.2 Subsequent Antepartum Care Visits GN-46
6.2.2.1 Physical Examination GN-46
6.2.2.2 Laboratory Tests GN-46
6.2.3 Postpartum Care Visit GN-46
6.2.4 Prior Authorization GN-47
6.3 Documentation Requirements GN-47
6.4 Claims Filing and Reimbursement GN-47
7. Gynecological Health Services GN-47
7.1 Assays for the Diagnosis of Vaginitis GN-47
7.2 Diagnostic Hysteroscopy GN-48
7.3 Abortions GN-48
7.3.1 Prior Authorization for Abortions GN-49
7.4 Examination Under Anesthesia GN-49
7.5 Hysterectomy Services GN-50
7.5.1 Hysterectomy Acknowledgment Form GN-50
7.6 Pap Smear (Cytopathology Studies) GN-51
7.7 Surgery for Masculinized Females GN-52
7.8 Documentation Requirements GN-52
7.9 Claims Filing and Reimbursement GN-52
7.10 National Drug Code (NDC) GN-52
8. Claims Resources GN-53
9. Contact TMHP GN-53
10. Forms GN-53
GN.1 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen, Instructions GN-54
GN.2 Specimen Submission Form G1-C, Maternal Serum Prenatal Triple Screen GN-55
GN.3 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen (Spanish, 2 Pages) GN-56
GN.4 Birthing Center Report (Newborn Child or Children) (Form 7484) GN-58
GN.5 Sterilization Consent Form Instructions (2 pages) GN-59
GN.6 Sterilization Consent Form (English) GN-61
GN.7 Sterilization Consent Form (Spanish) GN-62
GN.8 Abortion Certification-Statements Form GN-63
GN.9 Hysterectomy Acknowledgement Form GN-64
11. Claim Form Examples GN-65
GN.10 Family Planning Claim Form GN-66
GN.11 Maternity Service Clinic GN-67
GN.12 Nurse Practitioner/Clinical Nurse Specialist (Family Planning) GN-68
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