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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook : 3. Women’s Health Program (Title XIX Family Planning) : 3.3 Services, Benefits, Limitations, and Prior Authorization : 3.3.8 Sterilization and Sterilization-Related Procedures

3.3.8
Sterilization services may be reimbursed separately to family planning agencies or physicians. Sterilizations are considered to be permanent, once per lifetime procedures. Denied claims may be appealed with documentation that supports the medical necessity for a repeat sterilization.
The sterilization services that are available to WHP clients include surgical or nonsurgical sterilization, follow-up office visits related to confirming the sterilization, and any necessary short-term contraception. No other services are covered for WHP clients who have been sterilized.
The WHP covers sterilization as a form of birth control. To be eligible for a sterilization procedure through the WHP, the client must be 21 years of age or older and must complete and sign a Sterilization Consent Form within at least 30 days of the date of the surgery but no more than 180 days. In the case of an emergency, there must be at least 72 hours between the date on which the consent form is signed and the date of the surgery. Operative reports that detail the need for emergency surgery are required.
The WHP may reimburse providers for a follow-up visit that includes a hysterosalpingogram to ensure tubal occlusion, which is recommended three months after a hysteroscopic sterilization procedure. The WHP may also reimburse providers for short-term contraceptives dispensed following the insertion of an occlusive sterilization system.

Texas Medicaid & Healthcare Partnership
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