2SoonerCare & Perinatal Services Nearly 60% of Oklahoma births were reimbursed by SoonerCare in FY2008Perinatal Advisory Taskforce1 down, only 32,887 to go. . .SoonerCareOHCA has become the major insurance carrier in the state for pregnant women—last year 60% of OK’s births (nearly 55,000 babies are born in the state) were covered at least in part by SoonerCare.Several years ago, OHCA and OSDH began looking at how to improve birth outcomes in the state—PATF was formed—brings together major stakeholders in perinatal health—providers/university systems/OHCA/OSDH/agencies/organizations involved in perinatal health care.As a result many of OHCA’s perinatal benefits have been revised/improved to contribute toward quality care and improve health outcomes for mothers and their newborns while reducing costs associated with poor outcomes.
3Benefit Expansions 2006 Smoking/Tobacco Use Cessation Counseling Ultrasounds2007Perinatal DentalPrenatal Risk AssessmentObstetrical High Risk Care (i.e., NSTs, BPPs)Maternal & Infant Health Social Work ServicesLactation Consultation ServicesGenetic Counseling Services2008Soon-To-Be-SoonersThese are some of the revisions and expansions made during the last couple of years, this will serve as today’s agenda of what we plan to review and help you have a better understanding of SC perinatal benefits
4Smoking & Tobacco Use Cessation Counseling “5 A’s” InterventionAsk the patient to describe his/her smokingAdvise the patient to quitAssess the willingness of the patient to quitAssist with referrals and plans to quitArrange for follow-upThese benefits are for ALL SoonerCare members age 12 and over. We want to highlight this benefit in this training because tobacco cessation, important for everyone, is particularly important for pregnant women due to negative birth outcomes associated with smoking and tobacco use.1 in 5 pregnant women in OK smoke.Tobacco use in pregnancy is one of the single most important preventable causes of poor birth outcomes—it contributes to higher rates of low birth weight, preterm delivery, still birth and lots of pregnancy complications, i.e., miscarriage, premature rupture of membranes, etc.The 5 A’s methodology for tobacco cessation was created by the Agency for Healthcare Resarch and Quality (AHRQ) and is endorsed by the US Public Health Service as an evidence based method of assisting individuals in quitting tobacco useThere is strong evidence to indicate that providers addressing tobacco use with patients makes a difference and helps patients in reducing tobacco useMuch information is available through the US Surgeon General’s website on the 5 A’s and tobacco cessation, the website is listed on the SC handout behind your presentation--the handout describes the benefits available through SoonerCare
5Smoking/Tobacco Use Cessation Counseling--Provider Types PhysiciansPhysician assistantsNurse PractitionersNurse MidwivesOSDH & FQHC nursing staffDentistsMany providers are eligible to provide tobacco cessation benefits—many dentists are providing it, SC would like to see an increase in primary care providers and obstetrical care providers using the benefit
6Smoking/Tobacco Use Cessation Counseling Paid in addition to other appropriate services rendered on the same dayUp to 8 sessions/year per individual with documented tobacco useCoverage for SoonerCare, STBS and Insure Oklahoma IP99406—3-10 minute session99407—More than 10 minutesNo billing for less than 3 minutesService is paid in addition to any other service provided—paid in addition to global fees/E&Ms, etc.If someone asks what it pays– you may not want to give that info out since there is only one dental code (not broken out by time) and it pays a higher rate than physician code;- Fees are available on the website under Providers/Claim Tools/Fee Schedule—Up to 8 sessions per year, great for prenatal care providers, to address each visit;US Public Health services recommends adding tobacco use to vital signs, to be checked at every visit, (status may change, needs to be asked about)—5 A’s goes on to provide advice to quit and resources/help to quit
7Smoking/Tobacco Use Cessation Counseling Documentation OHCA 5 A’s Tobacco Cessation Counseling Documentation Form (CH-18)Chart documentation must include:A separate noteSeparate signaturePatient specific information addressed in the 5 A’sTime spent by the practitioner performing the counselingCopy of CH-18 in packet—may get from website—may use either the form or do own documentation
8Smoking & Tobacco Use Cessation Additional Support MedicationsZybanChantixNicotine Replacement ProductsNicotine patchesNicotine gumOklahoma Tobacco HelplineProducts available for all SC members, however, may or may not be appropriate during pregnancy, provider and patient will have to discussGive everyone tobacco helpline number—available for all Oklahomans—provides nicotine replacement products for uninsured
9Perinatal DentalLimited dental benefits for members who are pregnant &/or up to 60 days postpartumNo referral or PA requiredExamsRadiographyCleanings (including scaling and planing)FillingsExtractionsSmoking & Tobacco Use Cessation CounselingOHCA proud of this service, represents SoonerCare’s first time to provide adult dental benefits outside of emergency extractions;Available to pregnant SC members while pregnant and up to 60 days postpartum—not available for STBSNot as rich or full a benefit package as children’s dental but many important services are availableNo referral required, providers can be found on website, provider look-up
10Prenatal Risk Assessment Separate payment for initial assessment of pregnant memberMust complete both:American College of Obstetricians and Gynecologists (ACOG) Assessment FormOHCA Prenatal Psychosocial Assessment Form (CH-16)(English & Spanish versions)Prenatal Psychosocial Assessment form (CH-16) provides a comprehensive, standardized format for documentation and assessment of psychosocial problems—augments history and information contained in the ACOG form. Ideally completed on 1st visit to assess current issues that may affect pregnancy, i.e, domestic violence, basic needs/resources, etc. Page 1 is designed to be completed by patient; page 2 to be completed by practitioner or medical staff with the patient. Available on website in both English and Spanish. Form in your packet with instructions. May seem time consuming at first but many practices have begun using and found it got quicker/easier with time and they were getting much better information from patients and able to better address needs. May want to refer to Maternal and Infant Health Social Worker for services (talk about that in a few slides)
11Prenatal Risk Assessment Codes/Limits HCPC code H1000Limits:Two assessments per pregnancy(i.e., member changes providers during pregnancy)One assessment per providerProvide explananation about the limits—a woman may have two assessments if she changes providers—each provider may only bill one assessmentPays $30.00—paid in addition to other globals/E&Ms.
12OB Ultrasound Coverage Three categories:All Pregnant MembersPregnant members with suspected or identified fetal anomalies/maternal conditionsPregnant members with confirmed High Risk OB (approved High Risk OB PA)There has been some confusion about pregnancy ultrasounds—there are basically 3 categories for ultrasounds—Those that all pregnant SoonerCare members are eligible forThose that are for women needing further assessment due to suspicion of a problem with the pregnancy or babyThose in which a problem has been identified and high risk ob benefits are approved through a PAWe will review each category
13OB Ultrasounds All Pregnant Members: One First-Trimester (abdominal or transvaginal)CPT codes 76801/76817ANDOne Second- or Third-TrimesterCPT code 76805Performed by:OB/GYNRadiologistMFMNurse MidwifeFamily Practice PhysicianAdvanced Practice Nurse Practitioner in OB, certified in OB UltrasonographyALL pregnant SC members are eligible for 2 US—ONE in first trimester and ONE after first trimester (if you miss the one in first trimester, then you only get one after first trimester—no build up for not using the first)
14OB Ultrasounds Pregnant members with suspected or identified fetal anomalies/maternal conditions Assessment to confirm, performed by MFMOne fetal/maternal evaluation with detailed fetal anatomic exam (“Level II”)CPT codes 76811/76812Follow-upCPT code or 76817Up to 6 medically indicated follow-ups (additional require PA )Pregnancies that need further assessment to establish/confirm maternal/fetal high risk condition (medically necessary)—One Level 2 is covered when performed by an MFM; MFM may need to perform follow-up for confirmation—may do up to 6 follow-ups prior to PA76811—one per pregnancy—fetal/maternal eval and detailed fetal anatomic exam, single or 1st gestation76812—each additional gestation76816—Follow-up, re-eval of fetal size measurements, amniotic fluid volume, re-eval of organ systems for abnormalities
15OB Ultrasounds Pregnant members with confirmed High Risk OB (approved High Risk OB PA) Additional ultrasounds allowed for pregnant members with approved high risk obstetrical conditionsRequires High Risk OB Prior AuthorizationSee HROB slides (Referral and confirmation of approved maternal/fetal condition by MFM and approved OHCA CH-17)Moms with confirmed high risks and approval by OHCA medical authorization—may have up to 6 additional US—these may be performed by any qualified provider
16High Risk OB Care (HROB) Limited set of additional pregnancy care services for certain high risk maternal/fetal conditions (prior authorization required)Enhanced Antepartum ManagementFetal Nonstress TestsBiophysical ProfilesAdditional UltrasoundsAutomatic referral for SoonerCare Care ManagementSoonerCare recognizes the extra care and attention required in providing obstetrical care for women with medically high risk pregnancies. As of December 1, 2007, SoonerCare began offering expanded benefits for members who meet OHCA high risk pregnancy criteria. Providers of obstetrical care may seek prior authorization for additional reimbursement for the care of medically high risk pregnant women when co-managing care in consultation with a Maternal Fetal Medicine Specialist. HROB provides additional services for SC pregnant members with certain high risk conditions (maternal/fetal). Limited additional tests can be approved—NSTs, BPPs and US. Separate reimbursement is available for medically necessary fetal non-stress tests, biophysical profiles, and additional ultrasounds (beyond the standard benefit) when provided to SoonerCare members who meet the established criteria and services are prior authorized through the SoonerCare Medical Authorization Unit.Providers are eligible to receive supplementary per visit reimbursement for antepartum care of members with prior authorization for high risk OB services (paid in addition to global fees-$20 fee each time patient sees provider).Members authorized for High Risk OB Services are automatically referred to a SoonerCare Nurse Case Manager to assist with medical management, referrals and other services as needed.
17HROB Process High Risk OB services require PA PA approval process begins with MFM consultMFM 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 BPPPrimary OB and MFM are encouraged to co-manage care when appropriateMaternal-Fetal Medicine Specialist must see patient as first step in HROB PA process. Encourage providers to comanage care when appropriate between home OB provider and specialty provider (MFM).SoonerRide is available to help with transportation to specialistIn the future, it is hoped that telemedicine will help make this service easier to access in rural communities
18HROB-- 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 providersState employed physicians not eligible (due to the fact they are paid university system enhanced rate)HROB Prior Authorization requiredPaid in addition to E&M &/or global feesCode H1001
19HROB-- Tests/Procedures NOTE: Prior authorization required Additional UltrasoundsCombined limit of 6CPT Codes 76815, 76816, 76817Fetal Nonstress Tests and Biophysical ProfilesFetal Nonstress Tests (NST)CPT Code 59025Biophysical Profiles (BPP)CPT Code (with non-stress testing)CPT Code (without non-stress testing)limited to combined total of twelve (12) unitsCodes for HROB tests—PA approval required
20Required HROB PA Forms Fax: 405-702-9080 or 866-574-4991 Comprehensive assessment by MFM (signed by MFM with treatment recommendations)Chart notes documenting high risk conditionCH-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 SheetFax: orCopy of CH-17 in packet—may get on website;Complete both CH-17 and cover sheet—fax in with assessment by MFMEither MFM or home OB provider may fax in request—need to coordinate on this—MFM consultation/assessment must have treatment plan recommendations and be signed—CH-17 requests must not exceed recommendations in MFM assessment/treatment plan (MFM sig not required on CH-17 if consultant/notes have treatment recs and are signed by MFM)Providers that want antepartum management fee need to indicate and sign on CH-17
21Maternal & Infant Health Social Work Services Licensed Clinical Social Workers (LCSW) with training and experience in Maternal & Infant HealthServices for pregnant women with psychosocial factors/conditions that may lead to poor pregnancy &/or infant health outcomesDomestic violenceSubstance abuseLack of basic resourcesMental IllnessOther psychosocial concernsServices to help mother with issues outside of medical condition that may affect pregnancy—i.e., domestic violence, substance abuse, help in gaining resources for food/living conditions, mental health treatment, etc.
22Maternal & 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 requiredIndividual may self-referMay be referred by OB or other providerServices are covered:During pregnancyUp to 60 days postpartumReferred by any provider or self—listing of providers on website provider look-up—many providers willing to travel to provide services in other regions/counties—think about setting up a day of the week/month MIH SW could come into office and meet with patients, etc.Available to STBS as well, but ends at delivery (when STBS benefits end)Listing of SoonerCare contracted providers at
23Lactation Consultant Services Individualized care to address specific breastfeeding issues &/or manage lactation crisisFamiliarize and encourage members about this serviceCovered during pregnancy & up to 60 days postpartumNo formal referral requiredStrong evidence-base supports breastfeeding as one of the most readily available methods to improve the health status of childrenLC services support the initiation and duration of breastfeeding—many women start in the hospital but run into issues after discharge, need support/consultation—this service is intended to provide one-on-one support, training, expert helpAvailable for STBS but ends at delivery (when STBS benefits end)
24Lactation Consultant Services Listing of SoonerCare contracted providers atEligible ProvidersMust 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 contractWell-qualified providers--Please let moms know this service is available and how to access it--Providers listed on website—provider look-up
25Genetic CounselingServices for pregnant/postpartum SoonerCare members facing potential or diagnosed birth defectsServices provided by Licensed or Board Certified Genetic CounselorsReferred by OB or pediatric provider (usually by specialist)Available by referral for pregnant women carrying babies with possible birth defectsSoonerCare contracts with all licensed genetic counselors in the state
26Soon-To-Be-Sooners (STBS) Coverage of pregnancy related services for undocumented or non-citizen pregnant women residing in OklahomaThis program makes prenatal care services available to undocumented and non-citizen pregnant women in our state. This program was made available through a federal provision referred to as “services for the unborn child”. The idea is to provide health care services while women are pregnant to promote healthy birth outcomes.STBS is a slimmer benefit package than regular SoonerCare and covers only services that optimize the pregnancy and health of the baby.Providers and members are often confused about what services are covered under STBS. It is important to remember these services are intended to promote a health pregnancy and the healthiest outcome for the baby. Services, like regular prenatal care visits and labs, specialty services for things that affect the pregnancy, i.e., diabetic consultation, would all be covered. Services that affect the health of the mother exclusively and have no bearing on the pregnancy or health of the baby would not be covered, i.e., cataract surgery for the mother.
27Soon-To-Be-Sooners (STBS) EnrollmentPregnant women apply using regular SoonerCare application (SC-1)STBS members receive a member ID card and a welcome letter explaining the program and covered servicesIt is important to note that women must be enrolled in STBS for providers to bill antepartum care. Women enroll in the same manner as for SoonerCare—website apps or OKDHS office. Eligibility will indicate STBS.NOTE: Pregnant women must be enrolled in STBS for reimbursement of non-emergency services
28STBS Covered ServicesOffice visits related to the baby (antepartum care) including usual covered labs and ultrasoundsTwo office visits per month (outside of global antepartum care visits) for conditions that impact the pregnancy--i.e., specialists, lactation consultant, social workerHigh Risk OB services as medically necessary (prior authorization required)Services must be for the benefit of the unborn child (optimize pregnancy outcome)Routine prenatal care is covered similarly to regular SoonerCare.STBS are eligible for the benefits listed
29STBS Covered Services Maternal and Infant Health Social Work Services Lactation Consultation ServicesGenetic CounselingHospital services for the deliveryPatient advice linePharmaceuticals related to optimizing pregnancy outcomeSTBS covers 2 office visits for other conditions affecting the pregnancy along with Lactation Consultation, MIH Social Work, Genetic Counseling, etc., all included in 2/month—first in, first paid out billing
30STBS Excluded Services Services not covered for STBS:Dental servicesSoonerRide (transportation)Vision ServicesServices for conditions that do not impact pregnancy outcomeServices for the mother after deliveryNo coverage for family planning products or tubal ligationSome benefits are not covered for STBS—see slideRemember benefits end at delivery (hospital/delivery services are paid)Providers can bill global code (59400) that includes antepartum, delivery and postpartum—providers may not bill postpartum separatelyBecause this coverage is available as a health benefit for the “unborn child” (baby), family planning products and services, including tubals are not available for STBS members
31STBS Pharmacy Coverage Many prescription medications are covered for STBS members!Prescriptions are covered for pregnancy related conditions as medically necessaryMost STBS prescriptions require pharmacy PA (OHCA internal process—24 hour turn around)No pharmacy PA required for prenatal vitamins or Macrobid; (more coming soon)STBS covers many RxPrenatal vitamins and Macrobid will be filled right away at the pharmacy—a few other drugs are being added to this short list—other drugs are covered but most go through a pharmacy PA process—see next slide
32STBS Pharmacy PA Process Provider writes prescription as usual; calls in or sends Rx with member to local pharmacyProvider may send OHCA form “Pharm-4” with prescription to expedite pharmacy PA process—list diagnosis and reason why medically necessary for pregnancyIf no form sent, pharmacy will fax form to provider for completionPA usually processed within 24 hoursWrite Rx as normal—send with patient or fax/call pharmacyProvider can send “Pharm-4”—OHCA form available on website—to expedite pharmacy PA process—complete middle section as to why drug is necessary to optimize pregnancy/health of fetus and signIf you don’t send form, pharmacy will fax one for you to complete and sign—provider must complete and sign!Inform STBS members it may take a few hours or even up to one day to get medication filled—this does not mean they can’t get it, they may just need to wait and return in a few hours! (Not all meds are covered, but MANY are!)
33STBS 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 daysProviders must submit documentation with claimHCA-13 Electronic Paper Attachment Cover SheetSTBS claims are medically reviewedThis slows down the processing, claims—other than delivery-- will take a MINIMUM of 30 daysIt may be helpful to submit documentation with claims rather than wait for request for documentation
34Oklahoma Health Care Authority Electronic Claim Paper Attachment Form Cover SheetAExample of documentation attachment with claim
35STBS Deliveries & Reimbursement STBS alien global deliveries (antepartum & delivery) have a two stage reimbursement process1st--Payment is made on delivery portion only2nd--Payment is made on remainder of global (antepartum care portion)Paid on a monthly cycleSTBS deliveries are funded through both TXIX and TXXI and members fall into various categories of eligibility. This causes manual work to be completed in order for OHCA to properly process and pay out of correct funding bucket. This creates a two-step payment process that takes more time than most claims.Providers will bill global for antepartum and delivery but will first receive payment only for delivery; Payment will be sent later (monthly cycle) for antepartum portion of the global
36Newborn Arrival (after STBS) Newborns of mothers covered under STBS are U.S. citizens and are eligible for full scope SoonerCare benefitsNewborns receive up to 12 months SoonerCare eligibilityNewborns are added by OKDHS caseworker or electronic NB-1 process at hospitalAssure STBS moms their babies will be born US citizens and will be eligible for 12 months of SC eligibility, but they need to make sure their babies get enrolled (usually at hospital). They need to be thinking about who the baby’s provider will be so they can choose at enrollment.
37OHCA Perinatal Contacts Shelly PattersonPerinatal CoordinatorTerrie FritzDirector of Child HealthOHCA Child Health UnitPlease feel free to contact us with ideas/suggestions!