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    v1.0.28
    OpenPayerPolicy UpdatesObstetrics/GynecologyMississippi Medicaid maternity coverage update | O…
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    CurrentMississippi Division of MedicaidPolicy N/A

    Maternity Services (Antepartum, Delivery, Postpartum) Coverage Criteria

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    Rules governing coverage of maternity services (antepartum, delivery including inductions/cesarean, and postpartum care up to 12 months) for Mississippi Division of Medicaid beneficiaries.

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyMaternity Services (Antepartum, Delivery, Postpartum) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeRevised (operational history updated for SPA 23-0015)
    Effective DateApr 1, 2024
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionDocument medical necessity for inductions or cesarean sections performed more than one week before the treating physician's expected date of delivery.
    SourceLink
    POLICY UPDATE CHANGES

    Revised to correspond with MS SPA 23-0015 (effective 04/01/2023) with policy effective 04/01/2024.

    12 monthspostpartum coverage duration
    ≤1 week before EDDearly delivery timing
    24 conditionslisted indications
    possible

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    recoupment risk

    Coverage Criteria for Maternity Services

    General maternity services and medically necessary early delivery

    Covered when ALL of the following are met

    Maternity services scope: Antepartum, delivery, and postpartum services are covered as defined by the Division of Medicaid.

    Antepartum from conception to labor; postpartum up to 12 months; delivery includes labor and delivery.

    Early delivery coverage

    • Allowed medical/obstetric indications (ONE or more)

    The Division of Medicaid does not cover non-medically necessary early elective deliveries prior to the expected due date. Inductions of labor or cesarean sections performed before the treating physician's expected date of delivery are covered only when medical necessity is documented and a qualifying maternal or fetal condition is present.

    Examples of circumstances that constitute non-medically necessary early elective deliveries and are not covered include: maternal request; convenience of the beneficiary or family; maternal exhaustion or discomforts; availability of effective pain management; provider convenience; facility scheduling; suspected macrosomia with documented pulmonary maturity and no other medical indication; well-controlled diabetes; history of rapid deliveries; long distance between beneficiary and treating facility; and adoption.

    Coding and Timing Details

    No codes listed in documentmixed
    No codes listed
    Early delivery timing — prior to one (1) week before EDD
    Timing limit for early deliveryInductions of labor or cesarean sections prior to one (1) week before the treating physician's expected date of delivery require medical necessity documentation.
    Permitted when medically necessary for listed conditionsEarly delivery prior to one (1) week before EDD is covered only when medically necessary due to specified maternal or fetal conditions (e.g., non-reassuring fetal status, IUGR, preeclampsia, placenta previa/abruption, chorioamnionitis).
    Scope of allowed early deliveryThe list of indications is not exhaustive; examples are provided in the policy to guide medical necessity determinations.
    Postpartum coverage length — 12 months
    Postpartum coverage durationPostpartum services are covered for twelve (12) months following delivery, including any remaining days in the month in which the twelfth month occurs.

    Provider Actions, Documentation, and Review

    Prior Authorization

    Early delivery requires medical necessity documentation

    Inductions of labor or cesarean sections performed prior to one (1) week before the treating physician's expected date of delivery require documentation of medical necessity demonstrating one or more of the listed medical or obstetric conditions (e.g., non-reassuring fetal status, preeclampsia, placenta previa, IUGR, etc.).

    • Applies to inductions and cesarean sections before one (1) week prior to treating physician's expected date of delivery.
    • Medical necessity must reference one or more of the specified maternal or fetal conditions in the policy.
    Note

    Non‑covered early elective deliveries — provider note

    Providers must be aware that the policy explicitly excludes non‑medically necessary early elective deliveries (examples include maternal request, beneficiary or family convenience, provider or facility convenience, suspected macrosomia without other indication, well‑controlled diabetes, history of rapid deliveries, long distance, or adoption).

    Definitions

    Antepartum services
    DefinitionCare of a pregnant woman during the time in the maternity cycle that begins with conception and ends with labor.
    Coverage contextAntepartum services are one of the three core maternity service categories covered by the Division of Medicaid.
    IncludesRoutine prenatal visits and medically indicated antepartum management as defined by the treating clinician and policy criteria.
    Delivery services
    DefinitionCare involved in labor and delivery.
    Coverage contextDelivery services encompass both vaginal and cesarean deliveries and related intrapartum care.

    Background

    Maternity services covered by the Division include antepartum care (care from conception until labor), delivery care (labor and delivery, including induction and cesarean when medically necessary), and postpartum care. Postpartum coverage extends for twelve (12) months following delivery. Early deliveries (induction or cesarean) performed prior to one (1) week before the treating physician's expected date of delivery are permitted only when medically necessary and supported by documentation of an accepted obstetric or fetal indication. Medical records are subject to retrospective review and reimbursement may be recouped if coverage criteria are not met.

    Revision History

    2024-04-01revisionLatest

    Policy revised to correspond with MS SPA 23-0015; policy effective date 04/01/2024.

    2015-01-02revision

    Prior revision effective 01/02/2015 recorded in policy history.

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyMaternity Services (Antepartum, Delivery, Postpartum) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeRevised (operational history updated for SPA 23-0015)
    Effective DateApr 1, 2024
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionDocument medical necessity for inductions or cesarean sections performed more than one week before the treating physician's expected date of delivery.
    SourceLink
    On This Page
    Coverage Criteria for Maternity ServicesCoding and Timing DetailsProvider Actions, Documentation, and ReviewDefinitionsBackgroundRevision History
    Service components includedPostpartum coverage includes care of the mother in both hospital and office visit settings.
    Effective periodThe twelve-month period begins on the date of delivery and continues through the remainder of that month in the twelfth month.
  1. These exclusions are examples and are listed in the policy as non‑covered reasons for early elective delivery.
  2. Do not rely on convenience or maternal request as justification for early delivery coverage.
    3. Documentation Required

    Medical records will be reviewed retrospectively

    Medical records for deliveries will be subject to retrospective review to determine whether the delivery met the coverage criteria.

    • Retrospective review will examine documentation supporting medical necessity for early delivery.
    • Maintain complete clinical records that reference the specific obstetric/medical indication when early delivery is performed.
    Denial Risk

    Retrospective review may lead to recoupment of payment

    Reimbursement for hospital and professional services related to a delivery may be recouped if retrospective review determines the delivery did not meet the policy's coverage criteria.

    • If documentation does not support a covered medical/obstetric indication for early delivery prior to one (1) week before expected delivery, payment may be recovered.
    • Ensure documentation clearly ties the decision for early induction/cesarean to a listed medical indication to avoid recoupment.
    Early delivery note
    Deliveries (induction or cesarean) performed prior to one (1) week before EDD are allowable only when medically necessary per listed indications.
    Postpartum services
    DefinitionCare of the mother inclusive of both hospital and office visits following delivery for twelve (12) months including any remaining days in the month in which the twelfth (12th) month occurs.
    ScopePostpartum services are part of covered maternity services alongside antepartum and delivery care.
    Documentation implicationPostpartum care provided within this twelve-month period is subject to medical record review consistent with policy oversight.