CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Maternity Services

Defines coverage of maternity services (prenatal care, labor and childbirth, postpartum care) for in-network providers under specified Neighborhood Health Plan RI benefit packages, including included services, exclusions, and select program notes (home visits, education, lactation).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMaternity Services

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateMar 12, 2010

Next Review Date

Key ActionEnsure maternity services are provided by participating in-network providers (Obstetrician, OB/GYN, Family Practitioner, Nurse Midwife) or hospital; members may self-refer to participating providers in these categories.

POLICY UPDATE CHANGES

Version history lists Create Date 3/12/10 and revision/CPC review dates; no clinical policy statement changes indicated.

5Benefit Packages Listed

0Coverage Limits (none)

2Early Discharge Timing Windows

3Documented Review Dates

Coverage Summary

Scope: Defines coverage of Maternity Services including prenatal care, labor and childbirth, postpartum care, miscarriage, and complications of pregnancy for in-network providers under specified Neighborhood Health Plan RI benefit packages (RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners, Rhody Health Options Phase One).

Coverage stance: Covered with criteria — all maternity-related medical care provided by in-network practitioners is covered; members may self-refer to participating Obstetricians, OB/GYNs, Family Practitioners, or Nurse Midwives.

Payer/Subject: Neighborhood Health Plan of Rhode Island — Maternity Services.

Effective / Last review dates: Create Date 2010-03-12; last reviewed/PEC revision 2013-10-03 (version history also lists CMC review 2011-05-10).

Program-level points: There are no limits on covered maternity services rendered by in-network providers; listed benefit packages count = 5; documented review dates = 3.

Medical Necessity / Covered Criteria

Covered Maternity Services (Medically Necessary)

Covered when ALL of the following are met:

ALL of the following

Benefit package enrollment: Member is enrolled in one of the Benefit Packages listed (RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners, Rhody Health Options Phase One) or otherwise entitled to maternity benefits through Neighborhood Health Plan of Rhode Island.
In-network provider requirement: Services are provided by in-network participating Neighborhood doctor and/or hospital, including Obstetrician, Obstetrician/Gynecologist, Family Practitioner, or Nurse Midwife (members may self-refer to any participating provider in these categories).
Clinical relation to pregnancy: Service is related to pregnancy, childbirth, miscarriage, or complications of pregnancy (includes prenatal examinations, routine tests such as metabolic screening, diet regulation, delivery, hospital care, and postpartum care).

ref:

Home Health / Early Maternity Discharge Program

Covered when ALL of the following are met:

Early discharge timing: Member discharged from hospital within 48 hours of vaginal delivery or within 96 hours of Caesarean delivery.vaginal ≤48 hours; cesarean ≤96 hours

Home visit and HHA limits: Member receives up to one (1) home visit from an RN or pediatric nurse practitioner and up to four (4) hours per day for four (4) days of Home Health Assistance (HHA) following discharge.one RN/PNP visit; HHA up to 4 hours/day for 4 days

Childbirth Education and Parenting Classes

Covered when the following is met:

Education classes covered: Childbirth education and parenting classes provided to members.

No prior authorization required.

Lactation Services

Covered when ALL of the following are met:

Lactation services covered: Lactation services by a certified lactation consultant are covered.

Prior authorization requirement: Authorization is required after the first three (3) visits.after 3 visits

Obtain authorization after the member's first three visits with a certified lactation consultant.

Provider Actions & Operational Requirements

Documentation Required

In-network provider requirement

Ensure maternity services are provided by participating in-network providers or hospitals. Members may self-refer to participating Obstetrician, Obstetrician/Gynecologist (OB/GYN), Family Practitioner, or Nurse Midwife for prenatal and postpartum care.

Affected provider types: Obstetrician
OB/GYN (Obstetrician/Gynecologist)
Family Practitioner
Nurse Midwife

Prior Authorization

Lactation services prior authorization

Obtain prior authorization for lactation services once the member has had three visits with a certified lactation consultant; authorization is required after the first three visits.

Provider: certified lactation consultant
Threshold: authorization required after first 3 visits

Billing Rule

Home Health Assistance limits for early discharge

For members discharged early, provide up to one home visit from an RN or pediatric nurse practitioner and up to four hours per day of Home Health Assistance (HHA) for up to four days. These services apply when discharge occurs within 48 hours of a vaginal delivery or within 96 hours of a Caesarean delivery.

One (1) RN or pediatric nurse practitioner home visit
Home Health Assistance up to 4 hours per day for 4 days
Discharge timing: within 48 hours for vaginal delivery
Discharge timing: within 96 hours for C-section

Background

Maternity services encompass care for women during pregnancy (prenatal care), labor and childbirth, and postpartum care, and include prenatal examinations, routine tests (e.g., metabolic screening), diet regulation, delivery and hospital care for childbirth, miscarriage, and complications of pregnancy.

The policy confirms that all medical care related to pregnancy, childbirth or miscarriage provided by in-network practitioners is covered and explicitly states that there are no limits on covered maternity services rendered by in-network providers and practitioners.

Physician and hospital services for prenatal care, delivery, and postpartum care are covered when provided by a participating Neighborhood doctor and/or hospital; members may self-refer to participating Obstetrician, Obstetrician/Gynecologist, Family Practitioner, or Nurse Midwife.

Maternity services: Care for women during pregnancy (prenatal care), labor and childbirth, and postpartum care, including prenatal examinations, routine tests, diet regulation, delivery and hospital care for childbirth, miscarriage, and complications of pregnancy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMaternity Services

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateMar 12, 2010

Next Review Date

On This Page

OpenPayer

Maternity Services

Coverage Summary

Medical Necessity / Covered Criteria

Provider Actions & Operational Requirements

Coding

Background

Revision History