March 2, 2016

State of Alabama
Press Release: Medicaid

Changes in Covered Services for Pregnant Women

TO:     Physicians, Nurse Midwives, Plan First/Family Planning Providers, FQHC, IRHC,  PBRHC, Hospitals, Nurse Practitioners and Maternity Care Primary Contractors

 

PDF Version

 

In order to meet the federal requirements for coordination of benefits and minimum essential coverage, the Medicaid Agency has received approval from the federal government to provide full Medicaid for SOBRA (Pregnant Women) recipients. This means that SOBRA (Pregnant Women) who were once eligible for pregnancy-related services ONLY may now receive full Medicaid benefits throughout pregnancy and post-partum, whether the services were pregnancy related or not.  A Primary Medical Provider (PMP) referral is NOT required to receive non-pregnancy related services.

 

Emergency Services for Non-citizens - Changes have also been made to provide emergency services for non- citizen pregnant women throughout their pregnancy and during the post-partum period.  These emergency services do not have to be pregnancy related.  Previously, non-citizen pregnant women only received service through the HPE billing process for in-patient delivery services and all other pregnancy related services were billed manually.  The changes allow most non-citizen pregnant women claims for emergencies to be billed through HPE. These claims will require the certified emergency indicator in order to be considered for payment including deliveries.

 

Coverage and Billing - These coverage and billing changes will be retroactively effective back to November 1, 2015.  If a non-pregnancy related service for a SOBRA pregnant woman, or an emergency service prior to delivery (for a non-citizen pregnant woman) was provided on or after November 1, 2015, the provider is allowed to submit/resubmit the claim and Medicaid will consider it for reimbursement.  Claims that are pregnancy related will require a pregnancy related diagnosis code or a postpartum diagnosis code.  Co-pays may be applied for services that are non-pregnancy related.

 

A provider may reference the fee schedules for a list of covered services on this link.
The fee schedules are not an all-inclusive list of procedure codes covered by the Agency. 

 

Prior Authorization - For SOBRA adult recipients who now have full Medicaid benefits, retroactive to November 1, 2015, providers may submit a prior authorization (PA) for a date of service on or after November 1, 2015, if the procedure code requires a PA. For dates of service from November 1, 2015, to April 30, 2016, the PA must be received by HPE by June 30, 2016, for review. All other PAs for a date of service May 1, 2016, and after must be submitted timely, prior to rendering the service, and adhere to the normal submission guidelines in  Chapter 4, Obtaining Prior Authorization, and other applicable Chapters, such as Chapter 14, Durable Medical Equipment.

 

Eligibility - A recipient’s age, health care requirements, and place of residence may further define his or her eligibility for Medicaid covered services. For this reason, it is very important that the providers verify recipient eligibility and ensure they understand all aspects of the eligibility response.  Eligibility responses have been changed to reflect the correct coverage for these women. 

 

Providers are ultimately responsible for confirming recipient eligibility for services. It is recommended that providers verify eligibility electronically using their vendor, the Secure Web Port or AVRS at 1-800-727-7848 for confirmation of coverage.  For prior authorization requirements for the recipient and date of service in question the providers can contact the Provider Assistance Center at 1-800-688-7989.

 



  • For more information, visit http://medicaid.alabama.gov
  • For more state-wide press releases, click here