Mo. Code Regs. tit. 13 § 70-3.250

Current through Register Vol. 49, No. 23, December 2, 2024

Section 13 CSR 70-3.250 - Payment Policy for Early Elective Delivery

PURPOSE: This rule establishes the MO HealthNet payment policy for early elective delivery provided in any setting. The goal of this payment policy is to improve health outcomes for both the mother and child.

(1) The following definition(s) will be used in administering this rule:

(A) Early Elective Delivery-a delivery by induction of labor without medical necessity followed by vaginal or Caesarean section delivery or a delivery by Cesarean section before thirty-nine (39) weeks gestation without medical necessity.

(2) Early elective deliveries, or deliveries before thirty-nine (39) weeks gestation without a medical indication, shall not be reimbursed by the MO HealthNet Division (MHD). Those delivery-related services shall be denied or recouped by MHD. Non-payment includes services billed by the delivering physicians/provider and the delivering institution.

(3) Services determined to be caused by Early Elective Delivery-

(A) All services provided during the delivery-related stay at the delivering institution for maternal care related to an early elective delivery shall not be reimbursed by MHD. Non-payment or recoupment includes obstetric and institutional or facility charges; and

(B) Non-routine newborn services provided for newborns during the initial delivery-related stay at the delivering institution for conditions resulting from an early elective delivery and that are identified within seventy-two (72) hours of delivery may be subject to review and recoupment. Non-payment or recoupment includes facility or institutional charges.

(4) Payment for delivery prior to thirty-nine (39) weeks shall only be made if delivery is medically indicated.

(A) Services must be consistent with accepted health care practice standards and guidelines. MHD, through consultants, including expertise in obstetrics and pediatrics/neonatology, shall audit deliveries prior to thirty-nine (39) weeks gestational age that are billed to MHD for medical necessity and review those that would potentially be denied due to questions regarding medical necessity and non-routine services provided for newborns during the initial delivery related stay. Documentation must adequately demonstrate sufficient evidence of medical necessity to justify delivery prior to thirty-nine (39) weeks. Evidence shall include information of substantial nature about the pregnancy-complicating condition which is directly associated with the need for delivery prior to thirty-nine (39) weeks. Delivery will be considered medically necessary if without delivery, the mother or child would be adversely affected (significant and immediate impact on the normal function of the body, illness, infection, mortality).

(B) Delivery must be demonstrated to be-

1. Of clear clinical benefit and required for reasons other than convenience of the patient, family, or medical provider;

2. Appropriate for the pregnancy-complicating condition in question; and

3. Conform to the standards of generally accepted obstetrics practice as supported by applicable medical and scientific literature and as included in the MO HealthNet provider manuals and bulletins, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO. 65109, at its website www.dss.mo.gov/mhd, dated April 15, 2013.

(C) The determination of services caused by Early Elective Delivery shall be a final decision of the MO HealthNet Division.

(5) If a newborn or mother or both are transferred to another hospital for higher level care following standard medical practice, the receiving hospital shall not be subject to this early elective delivery policy. The hospital receiving the transfer shall be reimbursed following MHD reimbursement rules.

13 CSR 70-3.250

Adopted by Missouri Register August 15, 2014/Volume 39, Number 16, effective 9/30/2014