Wednesday, August 3, 2016

Billing Instruction for Sterilizations, Premature delivery

Voluntary Sterilizations 

Sterilization for the purpose of family planning is a benefit of the Colorado Medical Assistance Program in accordance with the following procedures:

General Requirements 
The following requirements must be followed precisely or payment will be denied. These claims must be filed on paper. A copy of the sterilization consent form (MED-178) must be attached to each related claim for service including the hospital, anesthesiologist, surgeon, and assistant surgeon.

† The individual must be at least 21 years of age at the time the consent is obtained.

† The individual must be mentally competent. An individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose cannot consent to sterilization. The individual can consent if she has been declared competent for purposes that include the ability to consent to sterilization.

† The individual must voluntarily give "informed" consent as documented on the MED-178 consent form (see illustration) and specified in the "Informed Consent Requirements" described in these instructions.

† At least 30 days but not more than 180 days must pass between the date of informed consent and the date of sterilization with the following exceptions:

Emergency Abdominal Surgery: An individual may consent to sterilization at the time of emergency abdominal surgery if at least 72 hours have passed since the member gave informed consent for the sterilization.

Premature Delivery: A member may consent to sterilization at the time of a premature delivery if at least 72 hours have passed since she gave informed consent for the sterilization and the consent was obtained at least 30 days prior to the expected date of delivery.

The person may not be an "institutionalized individual".

Institutionalized includes:

† Involuntarily confinement or detention, under a civil or criminal statute, in a correctional or rehabilitative facility including a mental hospital or other facility for the care and treatment of mental illness.

† Confinement under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.

If any of the above requirements are not met, the claim will be denied. Unpaid or denied charges resulting from clerical errors such as the provider's failure to follow the required procedures in obtaining informed consent or failure to submit required documentation with the claim may not be billed to the member.

Informed consent requirements

The person obtaining informed consent must be a professional staff member who is qualified to address all the consenting member’s questions concerning medical, surgical, and anesthesia issues.
Informed consent is considered to have been given when the person who obtained consent for the sterilization procedure meets all of the following criteria:

† Has offered to answer any questions that the member who is to be sterilized may have concerning the procedure.

† Has provided a copy of the consent form to the member.

† Has verbally provided all of the following information or advice to the member who is to be sterilized:

** Advice that the member is free to withhold or withdraw consent at any time before the sterilization is done without affecting the right to any future care or treatment and without loss or withdrawal of any federally funded program benefits to which the member might be otherwise entitled.

** A description of available alternative methods of family planning and birth control.

** Advice that the sterilization procedure is considered to be irreversible.

** A thorough explanation of the specific sterilization procedure to be performed.

** A full description of the discomforts and risks that may accompany or follow the performing of the procedure including an explanation of the type and possible effects of any anesthetic to be used.

** A full description of the benefits or advantages that may be expected as a result of the

** Advice that the sterilization will not be performed for at least 30 days except in the case of premature delivery or emergency abdominal surgery.

** Suitable arrangements have been made to ensure that the preceding information was effectively communicated to a member who is blind, deaf, or otherwise handicapped.

** The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.

· The consent form requirements (noted below) were met.

· Any additional requirement of the state or local law for obtaining consent was followed.

** Informed consent may not be obtained while the individual to be sterilized is:

 In labor or childbirth;
 Seeking to obtain or is obtaining an abortion; and/or
 Under the influence of alcohol or other substances that may affect the individual's sense of awareness.

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