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CurrentAlliance HealthPolicy 1E-6

Pregnancy Management Program (PMP)

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Defines the Pregnancy Management Program for NC Medicaid beneficiaries and governing requirements for providers who deliver obstetric services, including coordination with Local Health Departments and criteria for coverage and eligibility.

Policy Summary

PayerAlliance Health

PolicyPregnancy Management Program (PMP)

Policy CodePolicy 1E-6

Change TypeNo material change

Effective DateApr 1, 2023

Last ReviewApr 1, 2023

Next Review DateN/A

Key ActionComplete the standardized pregnancy risk screening form at the beneficiary's initial prenatal visit and refer those with priority risk factors to pregnancy care management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

No prior approvalNo PA for PMP ultrasounds

S0280 x3; S0281 x1Billing limits

All pregnant beneficiariesScreening requirement

60 daysPostpartum coverage end

Coverage Criteria — Pregnancy Management Program

inv-01: General Criteria Covered

Medicaid shall cover pregnancy management services when medically necessary and the following general criteria are met:

General Medical Necessity Criteria: a. The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs; b. The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

From 3.1 General Criteria Covered (chunks 17,18)

inv-02: Program Participation and Referral Criteria

Program participation and coordination requirements:

Provider Participation and Coordination: All providers eligible to bill NC Medicaid for obstetric services are considered participating PMP providers; providers must use the standardized pregnancy risk screening form to identify and refer women at risk for adverse birth outcomes to the Care Management for High-Risk Pregnancies (CMHRP) program and ensure coordination with Local Health Department care managers.

Policy Summary

PayerAlliance Health

PolicyPregnancy Management Program (PMP)

Policy CodePolicy 1E-6

Change TypeNo material change

Effective DateApr 1, 2023

Last ReviewApr 1, 2023

Next Review DateN/A

Key ActionComplete the standardized pregnancy risk screening form at the beneficiary's initial prenatal visit and refer those with priority risk factors to pregnancy care management.

SourceLink

On This Page

From Description and program features (chunk 6)

inv-03: General Criteria Covered

Covered when ALL of the following are met

General medical necessity: The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs.

from general criteria (chunk 18)

Safety and conservatism: The procedure, product, or service can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide.

from general criteria (chunk 18)

Not for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

from general criteria (chunk 18)

inv-04: Pregnancy Risk Screening and Care Management

Pregnancy risk screening and care management covered when ALL of the following are met

Screening population: All pregnant Medicaid beneficiaries participating in a PMP must receive pregnancy risk screening.

screening completed by specified clinicians (chunk 26)

Screening personnel: Screening must be completed by a physician, nurse practitioner, certified nurse midwife, physician assistant, or registered nurse.

From 3.2.2.6 (chunk 26)

Priority risk referral: If a priority risk factor is present on the pregnancy risk screening form, the beneficiary shall be referred for pregnancy care management assessment and a copy of the screening form provided to the high-risk case management agency.

Attachment B lists priority risk factors; referral requirement (chunk 36)

Care management timing: Pregnancy care management begins with the initial assessment and continues as long as need exists; it may begin postpartum if not identified antepartum and ends on the last day of the month in which the 60th postpartum day occurs.60 days postpartum (end of month)

From 3.2.2.7 (chunk 27) and 3.2.2.6/5.3.1 (chunks 27,36)

inv-05: Pregnancy Care Management Eligibility

Covered when ALL of the following are met

PMP eligibility and screening: Provider completes the standardized Pregnancy Risk Screening Form at the initial prenatal visit and at any follow-up when maternal or fetal condition changes; beneficiaries with a priority risk factor are referred for pregnancy care management assessment; pregnancy care management services are eligible any time during pregnancy and through the postpartum period ending the last day of the month containing the 60th post-delivery day. It is recommended screening be performed at visits closest to 28 and 36 weeks gestation.

From 5.3.1 and 3.2.2.7 (chunks 36,27)

inv-06: Provider Eligibility to Bill

Provider billing eligibility

Provider qualifications: Provider must meet Medicaid qualifications for participation, have a current and signed DHHS Provider Administrative Participation Agreement, and bill only for procedures, products, and services within their licensed scope of practice. Eligible provider types include individual physicians or physician groups, nurse practitioners, certified nurse midwives, and physician assistants enrolled with Medicaid providing obstetrical services in general medicine, family medicine, obstetrics and gynecology, multi-specialty practices, Federally Qualified Health Clinics (FQHC), Rural Health Clinics (RHC), or Local Health Departments (LHD).

See Sections 6.0 and 6.1 for provider eligibility and settings (chunks 37,38)

inv-07: PMP billing and screening

Covered when ALL of the following are met

PMP billing and provider criteria: Provider is a PMP provider billing usual and customary charges; completes the standardized Pregnancy Risk Screening Form at the initial prenatal visit and when biopsychosocial circumstances change (recommended at visits closest to 28 and 36 weeks); bills HCPCS S0280 after pregnancy risk screening and S0281 after the postpartum visit; S0280 may be billed a maximum of three times and S0281 a maximum of one time per gestation; the practice (not the individual clinician unless sole proprietor) is reimbursed for S0280/S0281; the provider billing S0281 must be the same provider billing the postpartum visit; with the exception of FQHCs and RHCs, one of the specified delivery CPT codes (59400, 59410, 59430, 59510, 59515) must be billed before S0281 is reimbursed; S0280 and S0281 are telehealth-eligible and telehealth may be used for screening and postpartum visits.S0280: maximum 3 times per gestation; S0281: maximum 1 time per gestation

From Attachment C and Sections C and G (chunks 56,60,63)

inv-08: OB ultrasound PA exemption and provider qualifications

Covered when ANY of the following are met

OB ultrasound PA exemption and medical necessity: The listed OB ultrasound CPT codes (Attachment D) are exempt from prior authorization for PMP providers; CPT codes 76811 and 76812 require medical necessity documentation (e.g., known or suspected fetal anatomic or genetic abnormality) and may only be performed by OB ultrasound providers certified by the American Institute of Ultrasound in Medicine (AIUM) or ACR-accredited practices, or by providers with subspecialty training in Maternal-Fetal Medicine (Perinatology) or Radiology.N/A

Attachment D lists exempt codes; performance restrictions for 76811/76812 (chunks 64,65,60)

Services may be denied or restricted when the Medicaid beneficiary's eligibility category imposes service limitations that make them ineligible for the service. Providers must verify each beneficiary's Medicaid eligibility at every visit to ensure the service is permitted under the beneficiary's eligibility category and avoid coverage denials.

Medicaid does not cover the procedure, product, or service when the beneficiary fails to meet eligibility requirements in Section 2.0, fails to meet the coverage criteria in Section 3.0, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial.

Prior approval requirements have been removed for certain services as reflected in the policy revision history. The policy revisions note that prior approval is no longer applicable where indicated; providers should consult the revision notes and applicable attachments for details on which services were affected.

Except for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), one of the specified delivery procedure codes (59400, 59410, 59430, 59510, or 59515) must be billed before HCPCS code S0281 will be reimbursed.

EPSDT does not require coverage of services that are unsafe, ineffective, experimental/investigational, or not medical in nature. Although EPSDT can override certain policy limitations for beneficiaries under 21 when medically necessary to correct or ameliorate a condition, it does not obligate coverage of services that fall into these excluded categories.

A service is considered not medically necessary and will not be covered if it is duplicative of another provider's service, if the beneficiary does not meet the eligibility or coverage criteria, or if the service is experimental, investigational, or part of a clinical trial.

CPT codes 76811 and 76812 require documented medical necessity (for example, a known or suspected fetal anatomic or genetic abnormality) and must be performed only by providers who meet the specified qualifications (AIUM-certified or ACR-accredited ultrasound providers, or Maternal-Fetal Medicine or Radiology subspecialists). Per the policy, these codes billed without appropriate medical necessity justification or provider qualifications are not considered medically necessary.

Coding — Codes, Limits, and Timeframes

OB Ultrasound Codes Exempt from Prior ApprovalmixedCovered

OB ultrasound codes

See Attachment D: OB Ultrasound Codes Exempt from Prior Approval for Pregnancy Management Program Providers

Ultrasound procedure codes (exempt list referenced)CPT

No codes listed

Claim Typemixed

Professional (CMS-1500/837P)

Claim type for professional services

Diagnosis CodingICD-10

ICD-10-CM

Diagnoses must be reported to the highest level of specificity in the current ICD-10 edition

PMP incentive HCPCS codesHCPCSCovered

S0280	PMP Pregnancy Risk Screening Form (billing after pregnancy risk screening tool completed)
S0281	PMP Postpartum plan maintenance (billing after postpartum visit completed)

OB ultrasound codes exempt from PACPTCovered

76801	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation.
76802	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional.
76805	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; single or first gestation.
76810	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; each additional gestation.
76811	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation.
76812	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation.
76813	Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation.
76814	Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation.
76815	Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses.
76816	Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a 76801).

1–10 of 20

1/2

Delivery-related CPT codes required before S0281 reimbursement (except FQHC/RHC)CPT

59400	Routine obstetric care including antepartum care, delivery, and postpartum care
59410	Vaginal delivery only (with or without episiotomy and/or forceps)
59430	Postpartum care only
59510	Routine obstetric care including cesarean delivery and postpartum care
59515	Cesarean delivery only

inv-24: Postpartum coverage end — last day of the month in which the 60th postpartum day occurs

Postpartum coverage end (policy text)Pregnancy care management services shall end on the last day of the month in which the 60th postpartum day occurs.

Where statedSection 3.2.2.7.a and 3.2.2.7.b specify end of care management on last day of month containing 60th postpartum day.

Implication for servicesPostpartum program services remain eligible through that month even if the 60th day falls earlier in the month.

inv-25: Postpartum coverage end — Last day of the month during which the 60th day post-delivery occurs

Postpartum coverage end (alternate wording)A beneficiary shall be eligible to receive pregnancy care management services at any time during pregnancy or the postpartum period which ends on the last day of the month during which the 60th day post-delivery occurs.

Source subsectionSection 5.3.1.d states the postpartum period end as last day of the month during which the 60th day post-delivery occurs.

Effect on eligibilityEligibility for pregnancy care management extends through that entire month, regardless of the exact calendar day the 60th day falls on.

inv-26: Postpartum visit timeframe — Within 56 days of delivery

Postpartum visit timeframe requirementEnsure comprehensive postpartum visits occur within 56 days of delivery.

Attachment C requirementAttachment C.h: Ensure comprehensive postpartum visits occur within (56) days of delivery.

Billing/recording implicationPostpartum visit timing supports billing of S0281 (postpartum plan maintenance) per program billing rules.

inv-27: S0280/S0281 billing limits — S0280: maximum 3 times per gestation; S0281: maximum 1 time per gestation

S0280 billing limitHCPCS S0280 may be billed a maximum of three times during the gestational period.

S0281 billing limitHCPCS S0281 may be billed one time during the gestational period.

Practice-level reimbursementThe PMP practice (not individual physician unless sole proprietor) is reimbursed for S0280 and S0281.

Single-biller ruleOnce billed, no other provider can bill these codes in the same gestational period.

Provider Actions — Prior Auth, Documentation, and Billing

Prior Authorization

Prior approval for OB ultrasound and EPSDT note

PMP providers: Prior approval requirements for obstetrical ultrasound follow EPSDT rules — some OB ultrasound codes are exempt from prior approval for Pregnancy Management Program providers; otherwise prior approval requirements remain as specified in policy and NCTracks guidance.

Some OB ultrasound CPT codes are exempt from prior authorization for PMP providers (see Attachment D).
When CPT codes require prior approval or medical necessity justification (see Attachment A and Reimbursement), follow NCTracks and payer PA processes.

Prior Authorization

Prior approval not required

No prior approval is required for enrollment in the Pregnancy Management Program, and PMP providers are not required to obtain prior approval for routine obstetrical ultrasounds listed as exempt in Attachment D.

Medicaid shall not require prior approval for the Pregnancy Management Program.
PMP providers are not required to obtain prior approval for obstetrical ultrasound codes listed in Attachment D.

Prior Authorization

Prior approval removal

Prior approval requirements have been removed for services where indicated in this policy and related revisions; providers must follow current policy language and Attachment D for PA-exempt ultrasound codes.

Policy revisions note that prior approval is no longer applicable where indicated (see Revision Information).
Attachment D lists OB ultrasound codes exempt from prior authorization for PMP providers.

Note

Eligibility verification and ineligibility

Providers shall verify each Medicaid beneficiary's eligibility at each service encounter; some beneficiaries may be ineligible for services based on their Medicaid eligibility category or other coverage rules.

Verify eligibility each time a service is rendered.
Services may be restricted or denied if the beneficiary's eligibility category does not cover the service.

Denial Risk

Denial triggers

Services may be denied for duplicative services, services that are experimental/investigational or part of a clinical trial, or when the beneficiary does not meet eligibility or covered criteria.

Duplicative services are subject to denial.
Experimental, investigational, or clinical trial services are not covered.
Beneficiary must meet policy eligibility and medical necessity criteria; otherwise services may be denied.

Billing Rule

Billing noncompliance

Billing noncompliance may result in denial or reimbursement issues. Use the most specific CPT/HCPCS/ICD-10 codes, follow limits on incentive codes, and ensure correct billing provider and frequency rules are followed.

Report ICD-10-CM/PCS and procedure codes to the highest level of specificity that supports medical necessity.
S0280 may be billed a maximum of three times per gestational period; S0281 may be billed one time per gestational period.
The PMP practice (not individual physicians except sole proprietors) is reimbursed for S0280 and S0281; the provider billing S0281 must also bill the postpartum visit.
Failure to use the most specific codes or to follow billing limits may trigger denial.

Documentation Required

Screening form and record retention

Providers must complete and retain the standardized Pregnancy Risk Screening Form at the beneficiary's initial visit and whenever maternal/fetal condition changes; a copy must be provided to the high-risk case management agency and retained per record access requirements.

Complete the standardized Pregnancy Risk Screening Form at the initial prenatal visit and at follow-up when the beneficiary's condition changes; recommended at visits closest to 28 and 36 weeks gestation.
Provide a copy of the completed form to the high-risk case management agency (CMHRP).
Allow health plans or designated vendors access to medical records for auditing and quality measurement; maintain records per applicable retention rules.

Billing Rule

Coding and record access

Providers shall report the most specific billing codes that accurately describe services and use current CPT, HCPCS, and ICD-10 coding editions; when no specific code exists use appropriate unlisted codes.

Report ICD-10-CM/PCS and procedure codes to the highest level of specificity that supports medical necessity.
Use current CPT, HCPCS, and UB-04 Data Specifications Manual editions in effect at the time of service.
If no specific code exists, report the service using the appropriate unlisted procedure or service code.

Note

General requirement

Services must be individualized, consistent with diagnosis/symptoms, safe, and provided when no equally effective, more conservative, or less costly treatment is available statewide.

Procedures, products, or services must be consistent with the beneficiary's symptoms or confirmed diagnosis and not in excess of need.
Services must be safe and not primarily for convenience.
Choose treatments that are equally effective and more conservative or less costly when available statewide.

Background — Program Overview

The Pregnancy Management Program (PMP) is a statewide care program with mandatory standards to improve prenatal, pregnancy, and perinatal care for Medicaid beneficiaries. It requires that all providers eligible to bill NC Medicaid for obstetric services participate in PMP activities such as using the standardized pregnancy risk screening form, coordinating referrals with Local Health Departments and Care Management for High-Risk Pregnancies (CMHRP), and following program requirements documented in attachments and revision notes.

Definitions and Key Terms

inv-45: High-Risk Pregnancy — A pregnancy that threatens the health or life of the beneficiary or fetus, often requiring specialized care.

DefinitionA pregnancy that threatens the health or life of the beneficiary or fetus, often requiring specialized care.

Context noteHigh-risk pregnancies are referenced throughout the PMP for screening and referral to CMHRP.

Clinical implicationMay trigger pregnancy care management assessment and enhanced case management services.

inv-46: Priority risk factors — Risk factors designated by the PMP model that require assessment by a care manager; listed in Attachment B and used to trigger referral t...

Priority risk factors (purpose)Risk factors designated by the PMP model that require assessment by a care manager and trigger referral; current list in Attachment B.

Where listedRefer to Attachment B for the list of priority risk factors used to trigger referral to case management.

Screening actionPresence of a priority risk factor on the pregnancy risk screening form requires referral for pregnancy care management assessment.

inv-47: Pregnancy care manager — A clinician who assesses high-risk pregnant beneficiaries and coordinates case management in the Care Management for High-Risk Pregnancy ...

Role of pregnancy care managerA clinician who assesses high-risk pregnant beneficiaries and coordinates case management in the Care Management for High-Risk Pregnancy Program (CMHRP).

Care initiationCare management begins with the initial assessment and continues as long as need exists; may begin postpartum if not identified antepartum.

Coordination requirementPregnancy care managers work in partnership with PMP providers to ensure proper care and refer beneficiaries to appropriate services at end of postpartum eligibility.

inv-48: Program timeframe — Pregnancy care management services timeframe: services are eligible during pregnancy and the postpartum period which ends on the last day...

Program timeframe (services eligible)Pregnancy care management services are eligible during pregnancy and the postpartum period which ends on the last day of the month containing the 60th post-delivery day.

Timing detailsCare management must begin with initial assessment and continue as long as need exists; may begin postpartum if not identified antepartum.

Referral and transitionAt the end of postpartum Medicaid eligibility, pregnancy care manager shall refer to Family Planning program or original provider as appropriate.

inv-49: Eligible providers — Eligible providers include physicians, nurse practitioners, certified nurse midwives, physician assistants enrolled with Medicaid providi...

Eligible provider typesIndividual physicians or physician groups, nurse practitioners, certified nurse midwives, and physician assistants enrolled with Medicaid providing obstetrical services in General Medicine, Family Medicine, Obstetrics and Gynecology, Multi-specialty, FQHCs, RHCs, or Local Health Departments.

Billing eligibilityProviders must meet Medicaid participation qualifications and have a current signed DHHS Provider Administrative Participation Agreement to bill for PMP services.

Scope of practiceProviders may bill only for services within their scope of clinical practice as defined by licensing and program requirements.

inv-50: High-risk pregnancy — A pregnancy with one or more risk factors such as prior preterm birth, low birth weight, multiple gestation, fetal complications, chronic...

High-risk pregnancy (risk examples)A pregnancy with one or more risk factors such as history of preterm birth, low birth weight, multiple gestation, fetal complications, chronic conditions complicating pregnancy (e.g., diabetes, hypertension, HIV, SLE), substance use, obesity, adolescent or advanced maternal age, unsafe living environment, missed prenatal appointments, or increased hospital utilization.

Non-exhaustive listAttachment B notes the list is not comprehensive for indications warranting case management.

Screening consequencePresence of these factors on the screening form requires referral for pregnancy care management assessment.

inv-51: PMP provider responsibilities — Providers billing global or pregnancy procedures who must follow PMP requirements including screening, care integration with CMHRP, reduc...

PMP provider responsibilities (summary)Providers billing global or pregnancy procedures must follow PMP requirements including completing the standardized Pregnancy Risk Screening Form, integrating care with CMHRP, reducing elective early deliveries and cesarean rates, and ensuring postpartum visits within 56 days.

Record access and qualityAllow Health Plan access to medical records for auditing and maintain measures to meet performance indicators.

Billing and screening dutiesPMP providers must bill S0280 after screening and S0281 after postpartum visit, and follow billing limits and reimbursement rules.