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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook

Gynecological and Reproductive Health and Family Planning Services Handbook
Table of Contents
1. General Information GN-7
1.1 Family Planning Overview GN-7
1.1.1 Guidelines for Family Planning Providers GN-8
2. Medicaid Title XIX family planning services GN-8
2.1 Title XIX Provider Enrollment GN-8
2.2 Services, Benefits, Limitations, and Prior Authorization GN-9
2.2.1 Family Planning Annual Exams GN-10
2.2.1.1 FQHC Reimbursement for Family Planning Annual Exams GN-11
2.2.2 Other Family Planning Office or Outpatient Visits GN-11
2.2.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits GN-12
2.2.3 Laboratory Procedures GN-12
2.2.3.1 Clinical Laboratory Improvement Amendments (CLIA) Requirement GN-12
2.2.3.2 Medical Record Documentation GN-12
2.2.3.3 Lab Specimen Handling and Testing GN-12
2.2.3.4 Providing Information to the Reference Laboratory GN-13
2.2.4 Radiology Services GN-13
2.2.5 Contraceptive Devices and Related Procedures GN-13
2.2.5.1 External Contraceptives GN-13
2.2.5.2 Intrauterine Device GN-13
2.2.5.2.1 Insertion of the IUD GN-13
2.2.5.2.2 Removal of the IUD GN-13
2.2.5.3 Contraceptive Capsules GN-13
2.2.6 Drugs and Supplies GN-14
2.2.6.1 Prescriptions and Dispensing Medication GN-14
2.2.6.2 Injection Administration GN-14
2.2.7 Medical Counseling and Education GN-15
2.2.8 Sterilization and Sterilization-Related Procedures GN-15
2.2.8.1 Sterilization Consent GN-15
2.2.8.2 Anesthesia for Sterilization GN-15
2.2.8.3 Occlusive Sterilization Device GN-15
2.2.8.4 Tubal Ligation GN-15
2.2.8.5 Vasectomy GN-15
2.2.8.6 Facility Fees for Sterilization GN-16
2.2.9 Prior Authorization GN-16
2.2.10 Non-covered Services GN-16
2.2.10.1 Family Planning Services for Undocumented Aliens GN-16
2.3 Documentation Requirements GN-16
2.4 Claims Filing and Reimbursement GN-16
2.4.1 Claims Information GN-16
2.4.1.1 Family Planning and Third Party Liability GN-17
2.4.2 Billing Procedures for Nonfamily Planning Services Provided During a Family Planning Visit (Title XIX Only) GN-17
2.4.3 National Drug Code GN-18
2.4.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines GN-18
3. Women’s Health Program (Title XIX Family Planning) GN-18
3.1 Women’s Health Program (WHP) Provider Enrollment GN-18
3.2 WHP Overview GN-18
3.2.1 Guidelines for WHP Family Planning Providers GN-18
3.2.2 Referrals GN-19
3.2.2.1 Referrals for Breast and Cervical Cancer Screening, Diagnostics, and Treatment GN-19
3.2.2.2 Referrals for Clients Diagnosed with Breast or Cervical Cancer GN-19
3.2.3 Abortions GN-19
3.3 Services, Benefits, Limitations, and Prior Authorization GN-20
3.3.1 Family Planning Annual Exams GN-21
3.3.1.1 FQHC Reimbursement for Family Planning Annual Exams GN-21
3.3.2 Other Family Planning Office or Outpatient Visits GN-21
3.3.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits GN-22
3.3.3 Laboratory Procedures GN-23
3.3.4 Radiology GN-23
3.3.5 Contraceptive Devices and Related Procedures GN-24
3.3.6 Drugs and Supplies GN-24
3.3.6.1 Prescriptions and Dispensing Medication GN-24
3.3.7 Instruction in Natural Family Planning Methods GN-25
3.3.8 Sterilization and Sterilization-Related Procedures GN-25
3.3.8.1 Sterilization Consent GN-25
3.3.8.2 Tubal Ligation GN-26
3.3.8.3 Anesthesia for Sterilization GN-26
3.3.8.4 Facility Fees for Sterilization GN-26
3.3.8.5 Hysteroscopic Sterilization GN-26
3.3.8.6 WHP Services After Sterilization GN-26
3.3.9 WHP Client Eligibility GN-26
3.3.9.1 Clients Who Have Received Sterilization Services GN-26
3.3.9.2 Eligibility Verification GN-27
3.3.10 Prior Authorization GN-27
3.4 Documentation Requirements GN-27
3.5 WHP Claims Filing and Reimbursement GN-28
3.5.1 Claims Information GN-28
3.5.1.1 WHP and Third Party Liability GN-28
3.5.2 Reimbursement GN-28
3.5.3 National Drug Code GN-28
3.5.4 NCCI and MUE Guidelines GN-28
4. Department of State Health Services (DSHS) Family Planning Program Services GN-28
4.1 Provider Enrollment for DSHS Family Planning Program Contractors GN-28
4.2 Services, Benefits, Limitations, and Prior Authorization GN-29
4.2.1 Family Planning Annual Exams GN-29
4.2.1.1 FQHC Reimbursement for Family Planning Annual Exams GN-30
4.2.2 Family Planning Office or Outpatient Visits GN-30
4.2.2.1 FQHC Reimbursement for Family Planning Office or Outpatient Visits GN-31
4.2.3 Laboratory Procedures GN-32
4.2.3.1 DSHS Family Planning Program GN-32
4.2.4 Radiology GN-32
4.2.5 Contraceptive Devices and Related Procedures GN-32
4.2.5.1 External Contraceptives GN-32
4.2.5.2 IUD GN-32
4.2.5.2.1 Insertion of an IUD GN-33
4.2.5.2.2 Removal of the IUD GN-33
4.2.5.3 Contraceptive Capsules GN-33
4.2.5.4 Medroxyprogesterone Acetate/Estradiol Cypionate GN-33
4.2.6 Drugs and Supplies GN-33
4.2.6.1 Prescriptions and Dispensing Medication GN-33
4.2.7 Family Planning Education GN-34
4.2.7.1 Medical Nutrition Therapy GN-34
4.2.7.2 Instruction in Natural Family Planning Methods GN-34
4.2.8 Sterilization and Sterilization-Related Procedures GN-34
4.2.8.1 Sterilization Consent GN-34
4.2.8.2 Incomplete Sterilizations GN-34
4.2.8.3 Tubal Ligation GN-34
4.2.8.4 Vasectomy GN-35
4.2.9 Prior Authorization GN-35
4.2.10 Reimbursement for WHP Wrap-Around Services GN-35
4.3 Documentation Requirements GN-35
4.4 Claims Filing and Reimbursement GN-35
4.4.1 Claims Information GN-35
4.4.1.1 Filing Deadlines GN-36
4.4.1.2 Third Party Liability GN-36
4.4.2 Reimbursement GN-36
4.4.2.1 Funds Gone GN-36
4.4.3 NCCI and MUE Guidelines GN-36
4.4.4 National Drug Code GN-36
5. Gynecological Health Services GN-37
5.1 Services, Benefits, Limitations, and Prior Authorization GN-37
5.2 Endometrial Cryoablation GN-37
5.3 Uterine Suspension GN-37
5.4 Salpingostomy GN-38
5.4.1 Prior Authorization for Salpingostomy GN-38
5.5 Assays for the Diagnosis of Vaginitis GN-38
5.6 Diagnostic Hysteroscopy GN-39
5.7 Abortions GN-39
5.7.1 Prior Authorization for Abortions GN-40
5.8 Examination Under Anesthesia GN-40
5.9 Laminaria Insertion GN-40
5.10 Hysterectomy Services GN-40
5.10.1 Hysterectomy Acknowledgment Form GN-41
5.11 Pap Smear (Cytopathology Studies) GN-42
5.12 Surgery for Masculinized Females GN-42
5.13 Documentation Requirements GN-42
5.14 Claims Filing and Reimbursement GN-43
5.14.1 NCCI and MUE Guidelines GN-43
5.15 National Drug Code GN-43
6. Claims Resources GN-43
7. Contact TMHP GN-44
8. Forms GN-44
GN.1 Sterilization Consent Form Instructions (2 pages) GN-45
GN.2 Sterilization Consent Form (English) GN-47
GN.3 Sterilization Consent Form (Spanish) GN-48
GN.4 Abortion Certification Statements Form GN-49
GN.5 Hysterectomy Acknowledgement Form GN-50
GN.6 Family Planning 2017 Claim Form GN-51
9. Claim Form Examples GN-52
GN.7 Family Planning Claim Form GN-53
GN.8 Nurse Practitioner/Clinical Nurse Specialist (Family Planning) GN-54
Index GN-55

Texas Medicaid & Healthcare Partnership
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