Termination of Pregnancy Reimbursement Policy
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Defines Select Health South Carolina's reimbursement stance and requirements for abortion procedures, including medically necessary care for spontaneous or complicated abortions, and specifies prior authorization and documentation requirements when applicable.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria
Select Health South Carolina will reimburse abortion procedures only as allowed by law and per the conditions below.
Medically necessary abortion types
- Treatment of spontaneous abortion/miscarriage is considered medically necessary.
- Treatment of incomplete abortion is considered medically necessary.
- Treatment of missed abortion is considered medically necessary.
- Treatment of septic abortion is considered medically necessary.
Prior authorization and documentation
- Except when performed to treat an emergency medical condition, prior authorization is required for abortion procedures.
- The Abortion Statement Form certifying and/or consenting to the termination must be submitted as part of the prior authorization process.
Referenced Coding Systems and Sources
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Prior Authorization and Required Documentation
Prior authorization and Abortion Statement Form required (except emergencies)
Except for abortions performed to treat an emergency medical condition, the provider must obtain prior authorization before performing the procedure. As part of the prior authorization submission, the provider must include the Abortion Statement Form certifying and/or documenting the member’s written informed consent to the termination.
- Prior authorization is required for non-emergency abortions.
- Submit the Abortion Statement Form with the prior authorization to certify consent and provider certification.
Definitions
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