CurrentAnthemPolicy G-06163

Sterilization, Reimbursement Policy

Defines Anthem Medicare Advantage reimbursement policy for sterilization procedures performed to render a member permanently incapable of reproducing, including documentation and billing considerations for participating providers.

Policy Summary

PayerAnthem

PolicySterilization, Reimbursement Policy

Policy CodePolicy G-06163

Change TypeBiennial review — no material change

Effective DateJun 29, 2022

Next Review DateN/A

Key ActionEnsure valid consent is properly executed with required signatures; consent does not need to be submitted with the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

informed consent not required with claimConsent form submission requirement

multiple surgery rules applyDelivery-associated billing

fee schedule/contracted ratePayment basis

CMS/ACOG/CFRGuidance sources

Sterilization Coverage Criteria

Sterilization coverage criteria

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Sterilization performed to render the member permanently incapable of reproducing.
ALL of the following
- The sterilization is a necessary part of the treatment of an illness or injury.
ALL of the following
- A valid informed consent form must be properly executed and include signatures from the member or the member's authorized representative, the person obtaining consent, and the physician performing the sterilization; include an interpreter's signature if applicable.

Policy Summary

PayerAnthem

PolicySterilization, Reimbursement Policy

Policy CodePolicy G-06163

Change TypeBiennial review — no material change

Effective DateJun 29, 2022

Next Review DateN/A

Key ActionEnsure valid consent is properly executed with required signatures; consent does not need to be submitted with the claim.

SourceLink

On This Page

Reimbursement, Billing Guidance, and Authorization

Billing Rule

Reimbursement and billing guidance

Reimbursement is based on the applicable fee schedule or contracted/negotiated rate. Anthem Medicare Advantage allows reimbursement of sterilization procedures performed to render a member permanently incapable of reproducing when the sterilization is a necessary part of treatment of an illness or injury. If a sterilization procedure is performed in conjunction with a delivery, multiple-surgery rules apply (see the Anthem Medicare Advantage Multiple and Bilateral Surgery policy). A properly executed valid consent form is required and must include signatures of the member (or authorized representative), the person obtaining consent, the physician performing the procedure, and an interpreter if applicable. An informed consent form does not need to be submitted with claims, but the billed codes must be supported by the medical record and office notes.

Anthem Medicare Advantage reimbursement = applicable fee schedule or contracted/negotiated rate
Sterilization covered when it is a necessary part of treatment for illness or injury
Multiple-surgery rules apply when performed with delivery — refer to Multiple and Bilateral Surgery policy
Valid consent form required (member/authorized representative, person obtaining consent, physician, interpreter if applicable) — consent not required to be submitted with claims

Denial Risk

Authorization and claims risk

Prior authorization and medical necessity requirements must be met per the member's benefit plan and applicable Anthem Medicare Advantage policies. Failure to follow appropriate coding, billing, authorization, or documentation requirements may result in claim rejection or denial, recovery/recoupment of payments, or adjustment of reimbursement to reflect appropriate services performed.

Claims must use industry-standard CPT, HCPCS, and/or revenue codes and be fully supported in the medical record/office notes
Anthem may reject or deny a claim, recover/recoup payment, or adjust reimbursement if guidelines are not followed
Providers must follow provider, state, federal, and CMS contract requirements which may supersede policy

OpenPayer

Sterilization, Reimbursement Policy

Sterilization Coverage Criteria

Coding and Consent Documentation

Reimbursement, Billing Guidance, and Authorization

Key Definitions