All temporary Pregnancy Management Program (PMP) flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.
As announced in NC Medicaid Bulletin Pregnancy Medical Home Transitioned to Pregnancy Management Program on October 19, 2021, Clinical Coverage Policy 1E-6, Pregnancy Medical Home is being replaced with Clinical Coverage Policy 1E-6, Pregnancy Management Program with an effective date of July 1, 2021. The policy is scheduled to post to the NC Medicaid Clinical Coverage Policy webpage on April 1, 2022.
The following permanent policy updates are being made for Medicaid beneficiaries in the PMP:
- Removing the enrollment requirement or process to “opt in” for participation in the program. All providers are considered participating PMP providers and will receive at a minimum, the same rate for vaginal deliveries as they do for cesarean sections.
- Clarifying continued use of the standardized Pregnancy Risk Screening Tool to identify and refer women at risk for an adverse birth outcome to the Care Management for High-Risk Pregnant Women (CMHRP) program.
- Adding the Pregnancy Risk Screen (incentive code S0280) and Postpartum Visit (incentive code S0281) as services that may be performed via telehealth. When submitting a claim for the appropriate incentive code above, a GT modifier should be billed with the code when the risk screen or postpartum visit was conducted via telehealth.
- Removing Clinical Coverage policy 1K-7, Prior Approval for Imaging Procedures references as prior approval for ultrasound is no longer applicable for the PMP.
- Updating Program Requirements for PMP providers as follows:
- Integrate the patient’s plan of care with local CMHRP staff, which is inclusive of collaboration and communication, ensuring access to HIPAA compliant space for adequate patient and CMHRP staff engagement, access to patients’ Electronic Medical Record (EMR) and to foster the embedded care management model;
- Allow health plan or health plan’s designated vendor access to medical records for auditing purposes to measure performance on specific quality indicators;
- Maintain or lower the rate of elective deliveries prior to 39 weeks gestation;
- Offer and provide 17 alpha-hydroxyprogesterone caproate (17p) for the prevention of preterm birth to women with a history of spontaneous preterm birth who are currently pregnant with a singleton gestation. 17p is prescribed when the beneficiary is deemed an appropriate candidate at the physician's discretion for 17p intramuscular injection and consents to participate after being informed by the provider of the benefits and risks;
- Complete the standardized risk screening tool at the initial prenatal visit and at any point when the beneficiaries’ biopsychosocial circumstances change;
- Decrease the cesarean section rate among nulliparous women;
- Decrease the primary cesarean section delivery rate if the rate is over the Department’s designated cesarean rate; Note: NC Medicaid sets the rate annually, which is at or below 20 percent; and
- Ensure comprehensive post-partum visits occur within 56 days of delivery
Providers are encouraged to review Clinical Coverage Policy 1E-6, Pregnancy Management Program for a detailed overview of other general language and formatting updates to the policy once the updated policy posts.
Contact
NCTracks Call Center: 800-688-6696