News

OB Ultrasound Reimbursed Fee for Service Which Require Prior Authorization (PA)

5/23/2017

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TO:   Physicians, Nurse Midwives, Plan First/Family Planning Providers, FQHC, IRHC, PBRHC, Hospitals and Nurse Practitioners Treating Medicaid Recipients in Districts 10 and 12 Only 

Prior authorization requests for OB ultrasounds must comply with Medicaid policy which requires:
•  All OB ultrasounds after the second ultrasound must be prior authorized.
•  The first date of service requested should be within 30 days of the date the PA is received by DXC Technology (formerly HPE).
•  Effective July 1, 2017, PA requests must be submitted to DXC Technology within 30 days of the first date of service requested. (NOTE: Electronic PA request and    upload of supporting documentation has been required since May 01, 2017).
•  Supporting documentation must be included, but requestors should only submit medical documentation related to the reason(s) for the additional ultrasounds, not    the entire patient record.
•  Medical information may be entered in the internal text of the PA or submitted as an electronic upload to DXC Technology
•  Date and diagnosis code of two previous Fee-for-Service ultrasounds must be included.

Examples of required information to be included on the PA include: 
•  Date(s) of the requested ultrasound(s); a date range is acceptable, as are multiple units on a single detail
•  Lists should include each date and diagnosis  for the prior ultrasounds for the current pregnancy
•  Recipient’s date of birth and Medicaid number
•  EDC-Estimated date of confinement
•  Medical diagnosis to substantiate the ultrasound(s) being requested
•  Benefit of the ultrasound(s) requested
•  Anticipated total number of ultrasounds for the current pregnancy

If information submitted does not include the required supporting documentation, the PA will be denied. Providers will have up to 30 days from the date of the denial letter to submit information for reconsideration. 

Resources for Providers:
•  Medicaid Website - Frequently Asked Questions related to submission of OB Ultrasound PAs  http://www.medicaid.alabama.gov/documents/5.0_Managed_Care/5.2_Other_Managed_Care_Programs/5.2.2_Maternity20Care/5.2.2_OB
_Ultrasound_PA_Requests_FAQs_12-9-16.pdf
•  Provider Billing Manual - Chapter 4 for information related to submitting PA requests.
•  Provider Billing Manual - Chapter 28, Physician, for the criteria related to obstetrical ultrasounds
http://medicaid.alabama.gov/content/gated/point_click.aspx

Please contact the Provider Assistance Center at 1-800-688-7989 if you have additional questions.



The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2017 American Medical Association and © 2017 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.

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