2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*– (b) Confined under a voluntary commitment in a mental hospital or other facilityfor the care and treatment of mental illness• (4) Recipients seeking sterilization must be given information regarding theprocedure and the results before signing a consent form. This explanation mustinclude the fact that sterilization is a final, irreversible procedure. Recipients mustbe informed of the risks and benefits associated with the procedure;.• (5) Recipients seeking sterilization must also be instructed that their consent canbe withdrawn at any time before the performance of the procedure and that theydo not lose any other Medicaid benefits as a result of the decision to have or nothave the procedure.• (6) Recipients voluntarily give informed consent to the sterilization procedure. See42 CFR Section 441.257(a):– (a) The consent to sterilization form is signed by the recipient at least 30 daysbefore performance of the operation, except in the case of premature deliveriesor emergency abdominal surgery when the consent form must be signed notless than 72 hours before the time of the premature delivery.– (b) A consent form is valid for 180 days from the date of signature.– (c) Consent is not valid if obtained during labor or childbirth, while the recipientis under the influence of alcohol or other drugs, or is seeking or obtaining aprocedure to terminate pregnancy.– (d) Providers obtaining the consent for sterilization must certify that to the bestof their knowledge that the recipient is eligible, competent, and voluntarilysigned the informed consent.– (e) Providers must provide an interpreter if needed to ensure that the recipientunderstands the information furnished.– (f) The recipient is given a copy of the completed, signed consent form and theoriginal is placed in the recipient’s medical record.• B. Hysterectomies: Medicaid covers only medically necessary hysterectomies. PHPdoes not cover hysterectomies performed for the sole purpose of sterilization. See42 CFR Section 441.253.• (1) Hysterectomies require a signed, voluntary informed consent whichacknowledges the sterilizing results of the hysterectomy. The form must be signedby recipients before the operation.• (2) Acknowledgement of the sterilizing results of the hysterectomy is not requiredfrom recipients who have been previously sterilized or who are past child-bearingage as defined by the medical community.• (3) An acknowledgement can be signed after the fact if the hysterectomy isperformed in an emergency.• C. Other covered services:• Medicaid covers medically necessary methods, procedures, pharmaceuticalsupplies and devices to prevent unintended pregnancy, or contraception includingoral contraceptives, condoms, intrauterine devices (IUD), depoprovera injections,diaphragms, and foams.NONCOVERED SERVICES: Reproductive health care services are subject to the samelimitations and coverage restrictions which exist for other Medicaid services. See SectionMAD-602, General Noncovered Services [now 8.301.3 NMAC, General NoncoveredServices].In addition, Medicaid does not cover the following specific services:• A. Sterilization reversalsF-122014 Practitioner and Provider Manual - Ver. 3