(A)
Nonpayable Services. The MassHealth agency does not
pay for a hysterectomy provided to a member under the following conditions.
(1) The hysterectomy was performed solely for
the purpose of sterilizing the member.
(2) If there was more than one purpose for
the procedure, the hysterectomy would not have been performed but for the
purpose of sterilizing the member.
(B)
Hysterectomy Information
Form. The MassHealth agency pays for a hysterectomy only when
performed by a licensed physician in a hospital, and the appropriate section of
the Hysterectomy Information (HI-1) form is completed, signed, and dated as
specified in
130 CMR 405.424(B)(1)
through (4).
(1)
Prior
Acknowledgment. Except under the circumstances specified below,
the member and her representative, if any, must be informed orally and in
writing before the hysterectomy operation that the hysterectomy will make her
permanently incapable of reproducing. (Delivery in hand of the Hysterectomy
Information (HI-1) form will fulfill the written requirement, but not the oral
requirement.) Section (B) of the Hysterectomy Information (HI-1) form must be
signed and dated by the member or her representative before the operation is
performed, as acknowledgment of receipt of this information. Whenever any
surgery that includes the possibility of a hysterectomy is scheduled, the
member must be informed of the consequences of a hysterectomy, and must sign
and date section (B) of the Hysterectomy Information (HI-1) form before
surgery.
(2)
Prior
Sterility. If the member is sterile prior to the hysterectomy
operation, the physician who performs the operation must so certify, describe
the cause of sterility, and sign and date section (C)(1) of the Hysterectomy
Information (HI-1) form.
(3)
Emergency Surgery. If the hysterectomy is performed in
an emergency, under circumstances that immediately threaten the member's life,
and if the physician determines that obtaining the member's prior
acknowledgment is not possible, the physician who performs the hysterectomy
must so certify, describe the nature of the emergency, and sign and date
section (C)(2) of the Hysterectomy Information (HI-1) form.
(4)
Retroactive
Eligibility. If the hysterectomy was performed during the period
of a member's retroactive eligibility, the physician who performed the
hysterectomy must certify that one of the following circumstances existed at
the time of the operation:
(a) the woman was
informed before the operation that the hysterectomy would make her sterile (the
physician must sign and date section (D)(1) of the HI-1 form);
(b) the woman was sterile before the
hysterectomy was performed (the physician must sign, date, and describe the
cause of sterility in section (D)(2) of the HI-1 form); or
(c) the hysterectomy was performed in an
emergency that immediately threatened the woman's life and the physician
determined that it was not possible to obtain her prior acknowledgment (the
physician must sign, date, and describe the nature of the emergency in section
(D)(3) of the HI-1 form).
(C)
Submission of the
Hysterectomy Information Form. Each provider must attach a copy of
the completed Hysterectomy Information (HI-1) form to each claim form submitted
to the MassHealth agency for hysterectomy services. When more than one provider
is billing the MassHealth agency for the same hysterectomy, each provider must
submit a copy of the completed HI-1 form.
