(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 the
appropriate section of the Hysterectomy Information (HI-1) form is completed,
signed, and dated as specified below.
(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 H1-1 form.