Service Requiring Adherence To Federal Guidelines

This policy section lists the Federally mandated guidelines and billing requirements
for sterilization, hysterectomy and abortion procedures. These guidelines must be adhered to in order to receive reimbursement from the Medical Assistance program
for these services. Detailed instructions for completing required forms, including examples of the forms, are outlined in this section.

Abortion Review Guidelines

• In accordance with Public Law 103-112, revision to the Hyde Amendment,
  the Rhode Island Department of Human Services (DHS) implemented the
  federal directive pertaining to Medicaid reimbursement for abortions.
  For dates of service on or after October 1, 1993, abortions may be performed for pregnancies resulting from rape, incest or as a result of life-threatening conditions of the mother.
• Reimbursement of abortions is based on the physician’s “Certification Statement” that the abortion was performed to save the life of the mother, to terminate pregnancy resulting from rape or to terminate pregnancy resulting from incest.
• Listed below are the physician certification statement’s that must accompany all claims for abortions for federal compliance and proper reimbursement. One of these statements with the Exact wording must be signed by the physician for an abortion to be paid. Substitute wording will not be acceptable.

“I, ( Physician’s Name) certify that on behalf of my professional judgment, the procedure performed was necessary to save the life of the mother, (Recipient’s full name and Medicaid number) of (Recipient’s complete address).”

___________________________________
Physician’s Signature

“I, (Physician’s Name) certify that on behalf of my professional judgment, the procedure performed on , (Recipient’s full name and Medicaid number) of (Recipient’s complete address) was necessary to terminate a pregnancy that
was the result of rape. I have counseled the recipient concerning the availability of health and social support services and the importance of reporting the rape to the appropriate law enforcement authorities.”

_________________________________
Physician’s Signature

“I, (Physician’s Name) certify that on behalf of my professional judgment, the procedure performed on, (Recipient’s full name and Medicaid number) of (Recipient’s complete address) was necessary to terminate a pregnancy that
was the result of incest. I have counseled the recipient concerning the availability of health and social support services and the importance of reporting the incest
to the appropriate law enforcement authorities.”

_________________________________
Physician’s Signature

The signature of the physician must be original script, NOT typed or rubber stamped.

• A copy of the signed certification statement must be submitted with each claim
  or reimbursement to be considered.
• The following diagnoses are payable if present on the claim:

• Claims billed with other than the approved diagnoses above will suspend
  for review.
• If the surgical procedure billed is a suspect abortion, claim is denied. An operative report, history & physical and pathology report are requested.
• D&C’s for incomplete or missed abortion is payable and should be
  coded appropriately.
• D&C’s for therapeutic or diagnostic purposes which is deemed
  medically necessary is payable and should be coded 58120.

Hysterectomy Acknowledge Consent Form

1. For hysterectomies, the appropriate acknowledgment consent form must be
   completed with the required signatures. The date of the signature may be the |
   date of surgery, providing the form was signed prior to the surgery being performed.
2. Hysterectomy acknowledgment consent forms are not required when the performing
   physician certifies and places his or her signature on the claim form or attachment
   that at least one of the following circumstances existed prior to surgery:
   
   Patient already sterile prior to the hysterectomy and the cause of the sterility
   is stated, such as congenital disorder or previously sterilized.
   
   Patient requires emergency hysterectomy because of a life-threatening situation. The
   physician must state the nature of the emergency and certify that he or she determined
   that prior acknowledgment was not possible. Since the acknowledgment may be
   signed the day of surgery, an emergency situation requires the patient be unconscious
   or under sedation and unable to sign the acknowledgment.
   The document must indicate the lack of patient signature on the Medical Assistance
   Hysterectomy Statement.
3. Hysterectomy acknowledgment consent forms with missing or incomplete signatures
   will be denied with the following message: “Consent Form Missing Or Invalid.”

Click on the link to download the Hysterectomy Consent Form

Sterilization Procedures

Payment of elective sterilization is NOT made if the recipient meets any of the following criteria:

1. Under 21 years of age at the time the consent form is signed.
2. Has been declared mentally incompetent for the purpose of sterilization (recipients are presumed to be mentally competent unless adjudicated incompetent for the purpose of sterilization).
3. Is institutionalized in a correctional facility, mental hospital or other rehabilitative facility
4. Gave consent in labor or childbirth, under the influence of alcohol or other drugs, or while seeking or obtaining an abortion.
5. A valid consent form is missing.

Consent Form

• Who Can Submit
• Physician
• Hospital
• Anesthesiologist

Hospitals may submit a copy of the consent form; however, surgeons are encouraged to submit the original if possible. In any case, the first consent form received by EDS will be evaluated to determine if the form is valid.

• What Is A Valid Consent Form
• Typewritten, blocked or facsimile stamped signatures are NOT acceptable for signature requirements.
• All blanks should be completed unless otherwise specified. Effective
  May 19, 1995, if consent forms are not readable, claims will be denied.
• All state-required and federally-required fields must be completed:
  (Fields 1-8, 11-16, 18). If required fields are left blank, the consent
  form is not valid and claims must be denied with a message stating “Missing or Incomplete Consent Form.”
• Any optional field may be left blank: (Fields 9-10, 17) unless indicated
  as applicable and identified below.
• If a valid consent form is submitted by either a surgeon, hospital or anesthesiologist, all claims can be paid if all other Medicaid requirements such as Medicaid eligibility are met.
• An interpreter must be provided if the consent form is not written in the language of the individual to be sterilized or the person obtaining consent does not speak the language of the individual. If an interpreter is used,
  the “Interpreter’s Statement” must be completed.
• The “Statement of the Person Obtaining Consent” must be completed
  by the person who explains the surgery and its implications, alternate methods of birth control, and the fact that the consent may be
  withdrawn at any time. The signature of the person obtaining consent
  must be completed at the time the consent is obtained. This must be an original signature, NOT a rubber stamp.
• The physician or the person obtaining consent must allow a witness
  of the recipient’s choice (if desired) when the consent is signed and/or arrangements must be made for handicapped individuals.
• The “Physician’s Statement” must be completed. The physician must indicate that 30 days or 72 hours have passed between consent and surgery by crossing out paragraph #1 or #2 as indicated on the
  consent form.
• The “Physician’s Statement” must be signed and dated on or after the
  day of surgery in all circumstances. This must be an original signature,
  not a rubber stamp.
• When a sterilization is performed at the time of a premature delivery,
  the expected date of delivery must be recorded in Field 17. The time
  of the recipient’s consent must be at least 72 hours prior to the actual delivery and 30 days prior to the expected date of delivery.
• When a sterilization is performed at the time of emergency abdominal surgery, the circumstances must be described in the appropriate area
  in Field 17. The time of the recipient’s consent must be at least 72
  hours prior to the surgery and 30 days prior to the expected date of delivery. If additional space is required, documentation may be
  attached to the consent form.
• The physician must review the consent form with the recipient shortly before the surgery.
• The actual sterilization procedure performed must be identical to that
  for which the recipient gave informed, written consent. Each reference
  to the sterilization procedure on the consent form and the claim form
  must be identical.
• The consent form is valid for 180 days from the date of the recipient’s signature.

Verification Guidelines For Sterilization Consent Forms

Click on the link to download the Sterilization Consent Form.