CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Termination of Pregnancy Physician Certification Form (rape/incest/life-threatening)

Governs the physician certification and submission requirements for Medicaid reimbursement of abortions performed for pregnancies resulting from rape, incest, or to save the life of the mother for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTermination of Pregnancy Physician Certification Form (rape/incest/life-threatening)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a signed physician certification statement (original handwritten signature required) with the claim by faxing the completed form to Utilization Management at 401-459-6023.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required physician certification statement form

401-459-6023UM fax/phone number for form submission

Originalphysician signature must be original

1993-10-01policy reference start date

Medicaid Reimbursement Eligibility

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTermination of Pregnancy Physician Certification Form (rape/incest/life-threatening)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a signed physician certification statement (original handwritten signature required) with the claim by faxing the completed form to Utilization Management at 401-459-6023.

SourceLink

On This Page

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Medicaid reimbursement eligibility for abortion

Covered when ALL of the following are met

Eligibility for Medicaid reimbursement of abortion: Abortion is performed because the pregnancy resulted from rape OR resulted from incest OR was necessary to save the life of the mother; AND a physician has completed and signed the certification statement attesting to this clinical indication; AND a copy of the signed certification is submitted with the claim.

Physician signature must be original (not typed or rubber-stamped).

The form does not list any additional exclusions beyond the clinical indication required on the physician certification. Coverage is conditioned on the certification statement explicitly indicating that the pregnancy resulted from rape, incest, or that the abortion was necessary to save the life of the mother. The physician's signature must be an original handwritten signature (not typed or rubber-stamped) and a copy of the signed certification must accompany each claim.

Abortions that do not meet the certification criteria—i.e., those not performed because the pregnancy resulted from rape or incest, or not required to save the life of the mother—are not eligible for Medicaid reimbursement under this policy implementation of the Hyde Amendment. A completed and signed physician certification statement must be submitted with the claim for reimbursement to be considered.

Provider Submission and Documentation Requirements

Prior Authorization

Submission / Authorization contact

Submit the completed form to Neighborhood Health Plan of Rhode Island's Utilization Management Department by fax at (401) 459-6023. Refer to Neighborhood's clinical policy site for detailed benefit, authorization and coverage criteria.

UM Fax: (401) 459-6023
UM Phone: (401) 459-6023 (use fax for form submission)

Denial Risk

Missing physician certification — risk of denied reimbursement

The physician certification statement must be an original handwritten signature (no typed or rubber-stamped signatures permitted). Failure to submit the signed physician certification statement with the claim may prevent Medicaid reimbursement.

Physician signature must be original script (handwritten).
A copy of the signed certification statement must accompany each claim for reimbursement.

Documentation Required

Required physician certification documentation

Required physician certification documentation: a signed physician certification statement certifying that the abortion was necessary because the pregnancy resulted from rape or incest or was necessary to save the life of the mother. The certification must use the prescribed wording and include the physician's full name, recipient's full name and NHPRI ID#, and the physician's handwritten signature and date. Substitute wording is not acceptable.

Physician's full name
Recipient's full name and NHPRI ID#
Certification that pregnancy resulted from rape or incest or was necessary to save the life of the mother (circle one)
Original handwritten physician signature (not typed or rubber-stamped)
Date of physician signature

Note

Form fields to complete

Complete all form fields on the Physician Certification Form: member information, provider information, clinical information, and authorization details. Ensure CPT codes, units, diagnosis and diagnosis code, gestational age, date(s) of service, provider contact details, and the treating physician's signature and date are filled in.

Member name, Member ID #, Member DOB
Provider name, Provider phone, Provider fax, Provider contact name, Place of service (city/town)/facility
Date(s) of service
CPT code(s) and units
Diagnosis and diagnosis code
Gestational age
Signature of treating physician (original handwritten) and date
Neighborhood decision/authorization fields (Authorization #, Dates of service, Services approved)

Policy Background

Neighborhood implements the federal Hyde Amendment as applied by the Rhode Island Department of Human Services. For dates of service on or after October 1, 1993, Medicaid reimbursement for abortion is permitted only when the pregnancy resulted from rape or incest, or when the abortion was necessary to save the life of the mother. Reimbursement relies on the treating physician’s signed certification attesting to one of these clinical indications; the form requires that the physician counsel the recipient about available health and social support services and the importance of reporting rape to authorities.

Key Definitions

Physician Certification Statement — key attributes

DefinitionSigned statement by the treating physician certifying that, in the physician's professional judgment, the abortion was necessary to terminate a pregnancy resulting from rape or incest or to save the life of the mother; must accompany each claim for reimbursement.

Signature requirementPhysician signature must be original handwritten script — not typed or rubber-stamped; substitute wording is not acceptable.

Submission requirementA copy of the signed certification statement must be submitted with each claim for reimbursement to be considered.

Required attestationsCertification must state the procedure was necessary because the pregnancy resulted from rape or incest (circle one) or was required to save the life of the mother; physician must indicate recipient name and NHPRI ID.

Counseling notePhysician must attest that they counseled the recipient about availability of health and social support services and the importance of reporting the rape to appropriate enforcement authorities.

OpenPayer

Termination of Pregnancy Physician Certification Form (rape/incest/life-threatening)

Medicaid Reimbursement Eligibility

Form Coding Fields

Provider Submission and Documentation Requirements

Policy Background

Key Definitions

CPT Code
Diagnosis Code