CurrentAlaska MedicaidPolicy N/A

Hysterectomy Certification and Consent Form Submission for Medicaid Reimbursement

This document governs the required completion, signatures, and submission of a Hysterectomy Certification and Consent form that must accompany Alaska Medicaid claims for hysterectomy reimbursement. It affects providers submitting Medicaid claims and Medicaid members undergoing hysterectomy in Alaska.

Policy Summary

PayerAlaska Medicaid

PolicyHysterectomy Certification and Consent Form Submission for Medicaid Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach the completed, signed Hysterectomy Certification and Consent form to the claim; failure to attach or submit an incomplete form will result in denial of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form required to be attached to claim

5form parts (I–V) required

907.644.6800Provider Inquiry (AK)

800.770.5650Provider Inquiry Toll-Free

Coverage Criteria for Hysterectomy Reimbursement

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Form submission and completeness criteria

Payment is contingent on submission of a fully completed and signed Hysterectomy Certification and Consent form with the claim.

Attach the completed, signed Hysterectomy Certification and Consent form to the claim for reimbursement.

Part I (Provider Information) must be completed by the provider.

Part II (Member Information) must be completed and must include member name, date of birth, Alaska Medicaid Member ID, date of hysterectomy, diagnosis code, and medical justification.

Part III (Informed Consent) must be completed and signed by the provider or designee, documenting whether oral and written information was provided, who provided it, the date, and provider/designee signature and date.

Part IV (Medicaid Member Consent) must be completed and signed by the Medicaid member indicating receipt and understanding of oral and written information and whether the information was given before or after the hysterectomy; if the member was unable to sign, proceed to Part V.

Part V (Provider Certification) must be completed with the required yes/no responses, explanations where requested (e.g., onset/cause of pre-existing sterility, reasons member was unable to sign, emergent/life‑threatening indication), and provider signature and date.

Failure to attach the form or submission of an incomplete form will result in denial of payment.

Required Coding and Clinical Details

Diagnosis codes required on formICD-10

Diagnosis(es) and medical justification to be entered on the form (diagnosis code referenced but not specified in this document).

Required clinical details

Required clinical detailsDiagnosis(es) and medical justification must be entered on Part II of the Hysterectomy Certification and Consent form (Diagnosis code and justification).

Location on formPart II: Medicaid Member Information — includes Member Name, DOB, Alaska Medicaid Member ID, Date of Hysterectomy, Diagnosis(es) and Medical Justification.

Responsible partyMust be completed by the provider as part of the claim attachment requirements.

Provider Submission Requirements and Risks

Denial Risk

Attach completed, signed form or risk denial

Submit the completed, signed Hysterectomy Certification and Consent form as an attachment to the claim for reimbursement. Failure to attach the Hysterectomy Certification and Consent form, or submission of an incomplete Hysterectomy Certification and Consent form will result in a denial of payment.

Attach the fully completed and signed Hysterectomy Certification and Consent form to the claim.

Documentation Required

Complete Parts I–V and obtain required signatures

Complete all applicable parts (I–V) of the Hysterectomy Certification and Consent form and sign/date where indicated, including provider information, member information, informed consent, member consent, and provider certification.

Part I — Provider Information: provider name, Alaska Medicaid ID, address, contact name/phone (must be completed by the provider).
Part II — Medicaid Member Information: member name, DOB, Alaska Medicaid ID, date of hysterectomy, diagnosis(es) and medical justification (must be completed by the provider).
Part III — Informed Consent: indicate whether oral and written information was provided, who provided it, date, and provider/designee signature and date.
Part IV — Medicaid Member Consent: member signature and date certifying receipt and understanding (before or after hysterectomy).
Part V — Provider Certification: answer required questions, provide explanations where requested, and include provider signature and date.

Definitions and Attestations

Informed consent

Informed consent requirementProvider/designee must document that oral and written information was provided explaining a hysterectomy will render the member permanently incapable of reproducing (Yes/No), with name, date, signature and date recorded on Part III.

Member acknowledgementPart IV must be completed and signed by the Medicaid member certifying they received and understood the oral and written information and indicating whether they received it before or after the hysterectomy.

Who signsSignature of Provider or Designee is required on Part III; Signature of Medicaid Member is required on Part IV (or skip to Part V if member unable to sign).

Provider certification

Provider attestation itemsProvider must certify on Part V whether the member was sterile prior to hysterectomy, whether the hysterectomy is for sterilization only, whether the member was unable to sign, and whether the procedure was emergent/life‑threatening — with explanations where requested.

Explanations requiredIf ‘Yes’ is indicated for prior sterility, inability to sign, or emergent indication, the form requires the provider to indicate onset date, cause(s), or explanation in the spaces provided.

Signature and datePart V requires the provider’s printed name, signature, and date to certify the attestation statements.