Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes the MO HealthNet payment
policy for early elective delivery provided in any setting. The goal of this
payment policy is to improve health outcomes for both the mother and
child.
(1) The following definition(s)
will be used in administering this rule:
(A)
Early Elective Delivery-a delivery by induction of labor without medical
necessity followed by vaginal or Caesarean section delivery or a delivery by
Cesarean section before thirty-nine (39) weeks gestation without medical
necessity.
(2) Early
elective deliveries, or deliveries before thirty-nine (39) weeks gestation
without a medical indication, shall not be reimbursed by the MO HealthNet
Division (MHD). Those delivery-related services shall be denied or recouped by
MHD. Non-payment includes services billed by the delivering physicians/provider
and the delivering institution.
(3)
Services determined to be caused by Early Elective Delivery-
(A) All services provided during the
delivery-related stay at the delivering institution for maternal care related
to an early elective delivery shall not be reimbursed by MHD. Non-payment or
recoupment includes obstetric and institutional or facility charges;
and
(B) Non-routine newborn
services provided for newborns during the initial delivery-related stay at the
delivering institution for conditions resulting from an early elective delivery
and that are identified within seventy-two (72) hours of delivery may be
subject to review and recoupment. Non-payment or recoupment includes facility
or institutional charges.
(4) Payment for delivery prior to thirty-nine
(39) weeks shall only be made if delivery is medically indicated.
(A) Services must be consistent with accepted
health care practice standards and guidelines. MHD, through consultants,
including expertise in obstetrics and pediatrics/neonatology, shall audit
deliveries prior to thirty-nine (39) weeks gestational age that are billed to
MHD for medical necessity and review those that would potentially be denied due
to questions regarding medical necessity and non-routine services provided for
newborns during the initial delivery related stay. Documentation must
adequately demonstrate sufficient evidence of medical necessity to justify
delivery prior to thirty-nine (39) weeks. Evidence shall include information of
substantial nature about the pregnancy-complicating condition which is directly
associated with the need for delivery prior to thirty-nine (39) weeks. Delivery
will be considered medically necessary if without delivery, the mother or child
would be adversely affected (significant and immediate impact on the normal
function of the body, illness, infection, mortality).
(B) Delivery must be demonstrated to be-
1. Of clear clinical benefit and required for
reasons other than convenience of the patient, family, or medical
provider;
2. Appropriate for the
pregnancy-complicating condition in question; and
3. Conform to the standards of generally
accepted obstetrics practice as supported by applicable medical and scientific
literature and as included in the MO HealthNet provider manuals and bulletins,
which are incorporated by reference and made part of this rule as published by
the Department of Social Services, MO HealthNet Division, 615 Howerton Court,
Jefferson City, MO. 65109, at its website
www.dss.mo.gov/mhd, dated April
15, 2013.
(C) The
determination of services caused by Early Elective Delivery shall be a final
decision of the MO HealthNet Division.
(5) If a newborn or mother or both are
transferred to another hospital for higher level care following standard
medical practice, the receiving hospital shall not be subject to this early
elective delivery policy. The hospital receiving the transfer shall be
reimbursed following MHD reimbursement rules.
