Updates to Requirements for the Consent for Sterilization Form The estimated effective date for this policy update is Aug. 1, 2022.

To maintain compliance with federal requirements, North Carolina Medicaid will be updating the 1E-3 Sterilization Procedures Policy with the following changes. The estimated effective date for this policy update is Aug. 1, 2022. 

The “Physician Statement” portion of the Sterilization Consent Form

• An update is in progress for the 1E-3 Sterilization Procedures policy that will require the unused final paragraph of the Physician’s Statement be crossed out or the claim will deny.
  • From the Sterilization Consent Form: “Instructions for use of alternative final paragraph: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual’s signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.”
• Once the update is implemented, the consent form will be considered “incomplete” unless the unused paragraph is crossed out.
• For consent forms which are considered “incomplete”, providers may resubmit a corrected sterilization consent form if a claim is denied for this reason. Claims resubmitted with a corrected and complete consent form will reprocess and pay appropriately.
• While sterilization claims will not begin to deny for this reason until the policy update is complete, providers are encouraged to begin crossing out the unused final paragraph of the Physician’s Statement when submitting all future Sterilization Consent Forms to prepare for this change.

The Use of Initials in Signatures in the Sterilization Consent Form

• Included in the upcoming update is a change that will allow for the use of initials in the signatures if the full name is printed below the signature which uses an initial.
• While the use of initials is permitted in the signature, the full name of the individual signing the form must be printed, no initials may be used in the printed name.
• Medicaid will still require a written signature, including the use of initials as described above; the use of electronic signatures or a signature stamp is not allowed.

Note: Some Standard Plans are already requiring providers to cross out the unused paragraphs in the “Physician Statement” of the sterilization forms. Please work with the Standard Plans to confirm their requirements. When the updated policy is implemented, all plans will be required providers to cross out the unused paragraphs in the “Physician Statement” of the sterilization forms. Please continue to monitor the NC Medicaid website. Another bulletin will be released when the effective date for this policy is confirmed that will further explain all changes to the policy.

Contact

NCTracks Call Center, 800-688-6696