14. Obstetrics & Gynecology
This chapter provides information about obstetric and gynecologic services and UCare’s Management of Maternity Services (MOMS) program.
Obstetric and Gynecology Services
Under Minnesota Statutes, Section 62Q.52, health plans must allow direct access without a referral or prior authorization for the following obstetric and gynecology services:
Annual preventive health examinations and any subsequent obstetric or gynecologic visits determined to be medically necessary by the examining provider
Evaluation and necessary treatment for acute gynecologic conditions or emergencies
Family Planning Services
UCare members have open access for family planning services. Members may obtain family planning services from any qualified provider, including those outside of the UCare network. Treatment for medical conditions of infertility is not an open access service, and must be obtained from a UCare contracted provider.
Sterilization is a family planning service. UCare members may obtain family planning services from any qualified provider, including those outside the UCare network. The Code of Federal Regulations (42 CRF 441.250-441.259) outlines requirements the member must meet for sterilization to be covered:
At least 21 years old at the time the consent form is signed
Informed consent must be given voluntarily and a consent form acceptable under federal regulations must be properly signed and witnessed by the patient, a witness, and the surgeon not less than 30 days or more than 180 days in cases of premature delivery or emergency abdominal surgery no less than 72 hours prior to completion of the surgical procedure. In the case of a premature delivery, consent must have been obtained 30 days prior to the expected due date.
The consent cannot be obtained when the member is:
The signed consent form must be retained in the member’s medical record.
Abortion Services | Minnesota Health Care Programs
UCare does not provide coverage for abortion services or make coverage decisions for MHCP members, except under certain circumstances.
All induced abortion and abortion-related services should be billed to the Minnesota Department of Human Services (DHS).
Abortion related services include:
Hospitalization when the abortion is performed in an inpatient setting.
The use of a facility when the abortion is performed in an inpatient setting.
Counseling related to the abortion.
General anesthesia or conscious sedation provided in conjunction with the abortion. Local and regional anesthesia, including nerve blocks, administered by the attending physician, is considered integral to the procedure and not separately billable.
Drugs provided during or directly after the abortion.
Uterine ultrasound following an abortion.
Abortion services codes (surgical induced abortion and medical abortion service codes).
Supplies (trays, Laminaria, etc).
Treatment of infection or other complications as a result of the abortion, (including treatment for an incomplete abortion).
Drugs (anti-anxiety, narcotics, anesthetics, antibiotics, etc).
b. Non-abortion related services and services performed for the pregnancy prior to the induced abortion should be billed to UCare. Non-abortion related services include:
- A history and physical exam
- Tests for pregnancy and venereal disease
- Blood tests
- Rubella titre
- Gonadotropin levels (hCG)
- Hemoglobin and hematocrit
- GAM (TM)
- Pap smear
- Laboratory examinations for the purpose of detecting fetal abnormalities
- Family planning services provided as a separate service
- Uterine ultrasound to confirm pregnancy
- RhD drugs
- Drugs used in conjunction with pregnancy or post-pregnancy state
Other non-induced abortion procedures, such as a pregnancy with fetal demise, missed abortion, or spontaneous abortion, are not subject to this process, and should be billed to UCare.
Abortion Services | UCare Medicare Plans
Members are allowed access without referral to UCare providers who perform abortion services. Services are covered under the standard Medicare benefit if they meet certain circumstances.
Medicare Advantage (UCare for Seniors) members have coverage for abortion services in the following situations:
1. A member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the member in danger of death unless an abortion is performed; or
2. The pregnancy is the result of an act of rape or incest.
UCare’s Management of Maternity Services (MOMS)
UCare’s MOMS program is designed to increase the number of pregnant members enrolled in prenatal care during the first trimester, decrease the rate of low birth weight, and increase the number of members who obtain postpartum visits. The program identifies the following focus areas: early prenatal care, risk factors such as age, high blood pressure, and diabetes; risk behaviors such as maternal use of tobacco, alcohol, or street drugs; and post partum care. UCare’s efforts are directed toward integration of services and increasing communication among those providing care to our members. Services and processes UCare has implemented to address the focus areas:
1. Early prenatal care. UCare members receive excellent prenatal care once initiated. UCare’s efforts to increase identification of our pregnant members and encourage early care-seeking behavior assure they receive the best clinical care. We designed several processes to encourage early prenatal care.
- A $75 gift certificate incentive to members for initiating care in the first trimester, or within 42 days of joining UCare.
- Customer Service sensitively asks callers if anyone in the home is pregnant.
- Outreach for assessment, education and referral:
- A telephonic outreach program attempts to reach all identified pregnant members aged 20+ in select counties for assessment, education and referral.
- Public Health home visits are available to pregnant members in the remaining counties and to all pregnant members under age 19.
2. Assessment & referral for risk behaviors. Throughout each pregnancy, UCare’s efforts focus on risk factors the member can mitigate.
- The telephonic outreach /Public Health home visit program assesses members regarding smoking behavior, nutritional needs, depression, chemical or alcohol use, medical risk factors and unmet social service needs.
- The call/visit includes an immediate referral to appropriate services.
- Follow up calls determine if the member has completed the referral.
- For pregnant smokers, UCare offers a $25 gift card incentive to complete an assessment with Mayo Clinic Tobacco Quit line.
3. Preparing for childbirth and caring for the new infant. Pregnant members can take childbirth preparation and infant care classes at no charge. Classes must be offered through UCare contracted providers. The following classes are included (and are billable):
- Childbirth Preparation, regular and refresher
- Cesarean Preparation and Vaginal Birth After Cesarean (VBAC) Classes
- Infant Care (does NOT include Infant CPR)
4. Well-baby visit. We believe that post partum visits assure members receive needed follow up education and assessment, as well as encouragement to seek routine well-baby checkups.
- A $75 gift card incentive to members for completing the postpartum visit.
- Public Health postpartum home visits are offered to all newly delivered members within several weeks of delivery.
5. Breastfeeding Education and Support. UCare offers breastfeeding education and support to pregnant and lactating members.
- Classes - Pregnant members can take breastfeeding classes at no charge. Classes are billable and must be offered through UCare contracted providers.
- Lactation Consultation - Lactating members can receive (inpatient) and/or outpatient breastfeeding assistance from a UCare contracted certified lactation consultant.
Breast Pumps - Breast Pump Coverage
A member who is breastfeeding and must be separated from their infant due to work or other reasons can order a breast pump at no cost. A medical order is required and some limits apply.
UCare covers three categories of breast pumps:
- Hospital Grade Rental Pumps (E0604) – Hospital grade electric pumps are available to members when they are unable to breastfeed their infants due to a medical condition (mother or infant). For example, if the infant is in the Newborn Intensive Care Unit and is unable to nurse, the hospital grade rental pump is the best choice as it will enable to the mother to establish and/or maintain her milk supply. A medical order is required, and there are limits to the length of rental time. Providers can submit documentation to extend the rental period. Available through hospitals and/or UCare contracted Durable Medical Equipment (DME) providers.
- Dual Electric Pumps (E0603) – Dual electric pumps are available through UCare contracted Durable Medical Equipment providers. These are purchased (not rental.) A medical order is required. There is a limit of one pump every three years.
- Note: Use of a hospital grade rental pump does not count towards the one pump per three years limit. This limit applies only to the purchased electric pump.
- Manual Pumps (E0602) – Manual pumps are available through UCare contracted DME providers. These are purchased (not rental). A medical order is required.
NOTE: Breast pumps are covered for members only after their babies are born. Breast pumps are not covered for pregnant members. Diagnosis codes must be one of the postpartum codes (V24.1-V24.2).
- Claims for breast pumps must be filed under the mother’s UCare number.
- Claims must include procedure code (E0604, E0603, or E0602), Diagnosis Code (V24.1 or V24.2), and the correct modifier indicating whether the claim is for a rental pump (RR) or a purchased pump (NU).
MOMS Billing Information
Reimbursement for services will be provided in accordance with your UCare provider contract.
Bill charges on the CMS 1500 claim form. Billing should include any of the enhanced services provided for the at-risk member.
You may bill for enhanced services if the UCare member has risk factors.
- H1001 At Risk Antepartum Management
- H1004 Postpartum Follow-up Home Visit
- H1002 Care Coordination
- H1005 Enhanced Package
H1003 Prenatal Health Education I and II and Prenatal Nutrition Education (submit this code with the appropriate amount of units when billing for more than one of these services on the same date of service).
Description of enhanced services
1. At Risk Antepartum Management: Primary care provider (MD/CNM) will be eligible for a reimbursement if the pregnant woman is determined to be at risk.
2. Care Coordination: Includes development, implementation and ongoing evaluation of a plan of care for the at risk pregnant women.
3. Prenatal Health Education I: Teaches general information on pregnancy and prenatal care; covers at risk medical conditions and behaviors that can be improved through education such as comfort measures, self care, self-detection and prevention of preterm labor, and childbirth process.
4. Prenatal Health Education II: Supplements Prenatal Health Education I for women who require more time and specialized education for at-risk behaviors such as smoking, alcohol, and drugs. Provides support and education for stress management, communication, self-esteem and parenting skills.
5. Prenatal Nutrition Education: Ongoing assessment of nutritional status and educational efforts to support a healthy pregnancy and infant. Referrals to food assistance programs such as WIC.
6. Postpartum Follow-up Home Visit: Home visit to be made within the first two weeks of the mother’s hospital discharge which includes assessment of mother’s and infant’s health, family planning. Parenting support and referrals to appropriate health and social services.
7. Enhanced Package: All of the above prenatal care services are provided.
For each MPAF completed, bill code H1001.
Prenatal Care Guidelines
Prenatal Care, Routine
Primary Source: Institute for Clinical Systems Improvement (ICSI)
Guideline: The following ICSI Guideline has been adopted as the UCare Clinical Practice Guideline with the noted modifications:
UCare Modifications of ICSI Guideline: Adopted without modifications.
Notation: HIV screening is recommended after general consent for medical care is obtained and the patient is notified that testing will be performed unless the patient declines (opt-out screening).
Rewards, Incentives & Resources
UCare’s Management of Maternity Services (MOMS) booklet is available in English and Spanish. Members who speak Somali receive a DVD in Somali, as well as the English booklet.
UCare’s Prenatal Care Incentive Program includes:
- $75 gift certificate after the initial prenatal appointment within the first trimester of pregnancy. Members, who join UCare after the first trimester, may earn a gift certificate if seen by a physician within 42 days of joining UCare.
- $75 gift certificate after the 6 week post-partum visit.
- $25 gift certificate for pregnant smokers completing an assessment with UCare's Tobacco Quitline
Pregnancy-related classes at no charge
Breast Pump Program
SEATS (Seats, Education, and Travel Safety) Program
Community Education Discounts
Smoking Cessation Program:
- Brochure: A Pregnant Woman’s Guide to Quit Smoking
- UCare's Tobacco Quitline
- Nicotine replacement therapy (patches, gum, etc.) are covered
Nurse Advice Line
UCare offers an after-hours nurse line, when the member’s primary care clinic is closed. The nurse advice line is staffed by registered nurses who provide fast access to health information and illness or injury treatment decision support. There is no charge for use of this service. The nurse advice line can be reached by calling 800-942-7858 or, for hearing-impaired members, 877-728-3311 (TTY).
Clinical Services: 612-676-6705 or 877-447-4384
24-hour nurse line: 800-942-7858
UCare Behavioral Health: 612-676-3300 or 1-888-531-1493 (follow the prompts)
Health Promotion: 612-676-3351 or 866-243-5157