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 Medicaid 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.
• Click here for diagnoses that are payable if present on the claim.
• Claims billed with other than the approved diagnoses 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. 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 Medicaid Hysterectomy Statement.
2. 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 Acknowledgement Form  
Click on the link to download the Hysterectomy Payment 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 Hewlett Packard Enterprise 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

Field # Consent to Sterilization

1Doctor’s Name Providing Information. Must be completed. If blank, denied as incomplete form.

2Name of Sterilization Procedure. Blank field is not acceptable. If blank,  denied as incomplete form. Procedures must match. Initials such as “TL” (Tubal Ligation) or “BTL” (Bilateral Tubal Ligation) may be used.

3Recipient’s Date of Birth. Blank field is not acceptable. Acceptable partial dates are: Month and Year Only, Month and Day Only if it is clear that the recipient was 21 years of age when the consent to sterilization was signed. If not or field is blank, denied as incomplete form.

4Recipient Name. First or Last names must be completed. If blank or first or last name only, denied as incomplete form.

5Doctor/Clinic. Blank field is not acceptable. Examples of acceptable information are: The name of the physician performing the sterilization, the name of the doctor/hospital clinic, or “Resident” of a specified clinic.

6Method of Sterilization. Blank field is not acceptable. The procedures must match.

7Recipient Signature. Blank field is not acceptable. If a recipient is unable to sign and must enter a mark “X”, one of the other signers should write out the recipient’s full name, placing their own initials by the recipient’s mark.

8Date of Recipient’s Signature. Blank or incomplete date is not acceptable. Time is not required unless the mandatory 30 day waiting period cannot be verified.

9Race and Ethnicity. Optional, not denied if blank.

Interpreter’ s Statement

10Interpreter’s Statement. If Interpreter is used, must be completed, signed and dated on or after the date the Consent to Sterilization and Statement of Person Obtaining Consent were signed and dated.

Statement of Person Obtaining Consent

11Recipient Name. Blank field is not acceptable. If blank, denied as incomplete form.

12Name of Sterilization Procedure. Blank field is not acceptable. If blank, denied as incomplete form. The procedures must match.

13Signature of Person Obtaining Consent. Blank field is not acceptable. If blank, denied as incomplete form. Typewritten or printed signatures are not acceptable. Rubber Stamps are not acceptable Facility Name and Address must be completed. If either is blank, denied as incomplete form.

Physician’s Statement

14Recipient Name. Blank field is not acceptable. If blank, denied as incomplete form.

15Date of Sterilization Procedure. Blank field is not acceptable. If blank, denied as incomplete form.

16Name of Sterilization Procedure. Blank field is not acceptable. If blank, denied as incomplete form. The procedures must match.

17Expected Date of Delivery. When a sterilization is performed at the time of a premature delivery, the expected date of delivery is required. 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. An emergency C-Section is not considered emergency abdominal surgery without documentation of emergency circumstances. If documentation is not present, denied for more information.

18Physician’s Signature. Blank field is not acceptable. If blank, denied as incomplete form. Typewritten or printed signatures are not acceptable. Rubber Stamps are not acceptable.

19Date of Physician’s Signature. Blank field is not acceptable. If blank, denied as incomplete form. The physician statement can be signed on or after the day of surgery.

Click on the link to download the Sterilization Consent Form - English
Click on the link to download the Sterilization Consent Form - Spanish