SOONERCARE Perinatal Services

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SOONERCARE Perinatal Services

• Provider Training

2009
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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
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Benefit Expansions

• 2006
• Smoking/Tobacco Use Cessation Counseling
• Ultrasounds
• 2007
• Perinatal Dental
• Prenatal Risk Assessment
• Obstetrical High Risk Care (i.e., NSTs, BPPs)
• Maternal Infant Health Social Work Services
• Lactation Consultation Services
• Genetic Counseling Services
• 2008
• Soon-To-Be-Sooners

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Smoking Tobacco Use Cessation Counseling

• 5 As 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

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Smoking/Tobacco Use Cessation Counseling--Provider
Types

• Physicians
• Physician assistants
• Nurse Practitioners
• Nurse Midwives
• OSDH FQHC nursing staff
• Dentists

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Smoking/Tobacco Use Cessation Counseling

• Paid in addition to other appropriate services
  rendered on the same day
• Up to 8 sessions/year per individual with
  documented tobacco use
• Coverage for SoonerCare, STBS and Insure Oklahoma
  IP

• 994063-10 minute session
• 99407More than 10 minutes
• No billing for less than 3 minutes

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Smoking/Tobacco Use Cessation Counseling
Documentation

• OHCA 5 As Tobacco Cessation Counseling
  Documentation Form (CH-18)

• Chart documentation must include
• A separate note
• Separate signature
• Patient specific information addressed in the 5
  As
• Time spent by the practitioner performing the
  counseling

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Smoking Tobacco Use Cessation Additional
Support

• Medications
• Zyban
• Chantix
• Nicotine Replacement Products
• Nicotine patches
• Nicotine gum
• Oklahoma Tobacco Helpline

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Perinatal Dental

• Limited dental benefits for members who are
  pregnant /or up to 60 days postpartum
• No referral or PA required
• Exams
• Radiography
• Cleanings (including scaling and planing)
• Fillings
• Extractions
• Smoking Tobacco Use Cessation Counseling

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Prenatal Risk Assessment

• Separate payment for initial assessment of
  pregnant member
• Must complete both
• American College of Obstetricians and
  Gynecologists (ACOG) Assessment Form
• OHCA Prenatal Psychosocial Assessment Form
  (CH-16)
• (English Spanish versions)

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Prenatal Risk AssessmentCodes/Limits

• HCPC code H1000
• Limits
• Two assessments per pregnancy
• (i.e., member changes providers during
  pregnancy)
• One assessment per provider

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OB Ultrasound Coverage

• Three categories
• All Pregnant Members
• Pregnant members with suspected or identified
  fetal anomalies/maternal conditions
• Pregnant members with confirmed High Risk OB
  (approved High Risk OB PA)

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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/GYN
• Radiologist
• MFM
• Nurse Midwife
• Family Practice Physician
• Advanced Practice Nurse Practitioner in OB,
  certified in OB Ultrasonography

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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-up
• CPT code 76816 or 76817
• Up to 6 medically indicated follow-ups
  (additional require PA )

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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)

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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

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HROB Process

• High 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

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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 EM /or global fees
• Code H1001

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HROB-- Tests/Procedures NOTE Prior
authorization required

• Additional Ultrasounds
• Combined limit of 6
• CPT Codes 76815, 76816, 76817
• Fetal Nonstress Tests and Biophysical Profiles
• Fetal Nonstress Tests (NST)
• CPT Code 59025
• Biophysical 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

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Required HROB PA Forms

• Comprehensive assessment by MFM (signed by MFM
  with treatment recommendations)
• Chart notes documenting high risk condition
• 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)
• HCA 13-A Cover Sheet
• Fax [phone] or 866-574-4991

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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 violence
• Substance abuse
• Lack of basic resources
• Mental Illness
• Other psychosocial concerns

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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 pregnancy
• Up to 60 days postpartum

Listing of SoonerCare contracted providers at
www.okhca.org
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Lactation Consultant Services

• Individualized care to address specific
  breastfeeding issues /or manage lactation crisis
• Familiarize and encourage members about this
  service
• Covered during pregnancy up to 60 days
  postpartum
• No formal referral required

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Lactation Consultant Services
Listing of SoonerCare contracted providers at
www.okhca.org

• Eligible Providers
• Must 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

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Genetic Counseling

• Services for pregnant/postpartum SoonerCare
  members facing potential or diagnosed birth
  defects
• Services provided by Licensed or Board Certified
  Genetic Counselors
• Referred by OB or pediatric provider (usually by
  specialist)

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Soon-To-Be-Sooners (STBS)

• Coverage of pregnancy related services for
  undocumented or non-citizen pregnant women
  residing in Oklahoma

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Soon-To-Be-Sooners (STBS)

• Enrollment
• Pregnant 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
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STBS Covered Services

• Office 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 worker
• High Risk OB services as medically necessary
  (prior authorization required)

• Services must be for the benefit of the unborn
  child (optimize pregnancy outcome)

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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

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STBS Excluded Services

• Services not covered for STBS
• Dental services
• SoonerRide (transportation)
• Vision Services
• Services for conditions that do not impact
  pregnancy outcome
• Services for the mother after delivery
• No coverage for family planning products or tubal
  ligation

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STBS Pharmacy Coverage

• Many prescription medications are covered for
  STBS members!

• Prescriptions are covered for pregnancy related
  conditions as medically necessary
• Most STBS prescriptions require pharmacy PA (OHCA
  internal process24 hour turn around)
• No pharmacy PA required for prenatal vitamins or
  Macrobid (more coming soon)

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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 processlist
  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

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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 days
• Providers must submit documentation with claim
• HCA-13 Electronic Paper Attachment Cover Sheet

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Oklahoma Health Care Authority Electronic Claim
Paper Attachment Form Cover Sheet
100123456A
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STBS Deliveries Reimbursement

• STBS alien global deliveries (antepartum
  delivery) have a two stage reimbursement process
• 1st--Payment is made on delivery portion only
• 2nd--Payment is made on remainder of global
  (antepartum care portion)
• Paid on a monthly cycle

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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

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OHCA Perinatal Contacts

• Shelly Patterson
• Perinatal Coordinator
• 405-522-7332
• Shelly.Patterson_at_okhca.org
• Terrie Fritz
• Director of Child Health
• 405-522-7377
• Terrie.Fritz_at_okhca.org
• OHCA Child Health Unit
• 405-522-7188

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The End!
Questions?