Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2006 Title: Pregnancy Coverage Issues
Revision Date: 01/01/2019 Document: BI161:00
CPT Code(s): 59100-59870
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

If you are covered by a plan that covers you for pregnancy-related care, all care related to the pregnancy is covered, provided your plan is in effect on the date of service, with two exceptions:

1. If you are a registered inpatient in a hospital or other inpatient facility on the date you would otherwise be entitled to begin coverage, you will not be eligible for coverage under your policy and will not receive coverage for such inpatient confinement.  Your previous carrier will be responsible for all hospital charges, including the global obstetrician charges if you deliver during that confinement.  If you have no prior coverage, there will be no coverage for that confinement.

2. If you cease to be covered by QualChoice prior to your delivery, your new carrier is responsible for the global charge from your obstetrician; it should not be billed in partial amounts to the two carriers.

If you are covered by a plan that does not cover you for pregnancy-related care, routine pregnancy care and delivery are not covered. This includes all services before and after delivery that are related to the pregnancy itself. Complications of the pregnancy, as defined in this Medical Policy, will be covered even though routine pregnancy care will not be covered. A difficult pregnancy or difficult delivery is not a complication of pregnancy.  Routine Caesarian section is not considered a complication of pregnancy and is therefore not covered under these plans.


Medical Statement

If the plan covers pregnancy:

  1. Federal law prohibits the application of pre-existing condition exclusions to pregnancy care in all instances in which pregnancy care is covered.
  2. In all instances where pregnancy care is covered, all complications of pregnancy are also covered and pre-existing condition exclusions do not apply.
  3. If the member changes plans in mid-pregnancy, the new plan (the one covering her at the moment of her delivery) is responsible to pay all global charges related to the pregnancy and delivery. All episodic charges – charges that point to single episodes of care (like drawing lab work) that arise are paid by the carrier in effect on the date of service.
  4. Exception: If the member is hospital confined for delivery at the time where coverage changes, the prior carrier is responsible up to discharge, to include the global OB fee.

If the plan does not cover pregnancy:

  1. Pre-existing condition exclusion does not apply because it is a non-covered service.
  2. All pre-natal and post-natal services related to the pregnancy are not covered.
  3. If a complication of pregnancy arises relating to a pregnancy that was not pre-existing at enrollment, then the complication is covered even though the pregnancy is not covered.   
    1. Admission for the following complications of pregnancy will be covered:  HELLP syndrome, uterine rupture, amniotic fluid embolism, chorioamnionitis, fatty liver in pregnancy, septic abortion, placenta accreta, gestational hypertension, puerperal sepsis, per partum cardiomyopathy, cholestasis in pregnancy, thrombocytopenia in pregnancy, placenta Previa, placental abruption, acute cholecystitis in pregnancy, pancreatitis in pregnancy, pelvic septic thrombophlebitis, postpartum hemorrhage, retained placenta, air embolus, miscarriage, adnexal mass in first trimester, Hydatidiform mole, or ectopic pregnancy
    2. There are many conditions that can be aggravated by, or require treatment because of pregnancy. Some examples include:  acute nephritis, nephrosis, cardiac decompensation, hyperthyroidism, hepatitis B or C, HIV, HPV, abnormal Pap smear, syphilis, Chlamydia, herpes, UTI, thromboembolism, appendicitis, hypothyroidism, pulmonary embolism, sickle cell disease, tuberculosis, migraine headaches, depression, acute myocarditis, asthma, maternal cytomegalovirus, urolithiasis, DVT prophylaxis, ovarian dermoid tumors or cirrhosis. All of these can occur with or without pregnancy and are therefore medically covered.
  4. Emergency cesarean section is covered as a complication of pregnancy. Cesarean section performed solely because of a previous cesarean section, or performed for the convenience of the patient or the physician, is not a complication of pregnancy and will not be covered. 

Codes Used In This BI:

59100

Hysterotomy, abdominal

59120

Surgical tx of ectopic pregnancy; tubal/ovarian, req salpingectomy and/or oophorectomy, abd/vag approach

59121

     tubal/ovarian, w/o salpingectomy and/or oophorectomy

59130

     abdominal pregnancy

59135

     interstitial, uterine pregnancy requiring total hysterectomy

59136

     interstitial, uterine pregnancy w/partial resection of uterus

59140

     cervical, w/evacuation

59150

Laparoscopic tx of ectopic pregnancy; w/o salpingectomy and/or oophorectomy

59151

     w/salpingectomy and/or oophorectomy

59160

Curettage, postpartum

59350

Hysterorrhaphy of ruptured uterus

59400

Routine obstetric care incl antepart care, vaginal delivery & postpart care

59409

     vaginal delivery only

59410

     incl postpartum care

59414

Delivery of placenta (separate procedure)

59425

Antepartum care only; 4 - 6 visits

59426

     7 or more visits

59430

Postpartum care only (separate procedure)

59510

Routine obstetric care incl antepart care, cesarean delivery, & postpart care

59514

Cesarean delivery only

59515

     incl postpartum care

59610

Routine obstetric care incl antepart care, vag deliv & postpart care, aftr prv cesarean deliv

59612

Vaginal deliv only, after prv cesarean deliv

59614

     incl postpartum care

59618

Routine obstetric care incl antepart care, cesarean deliv, & postpart care, follow attemp vag deliv aftr prev cesarean deliv

59620

Cesarean delivery only, follow attempt vag deliv aftr prev cesarean deliv

59622

     incl postpartum care

59812

Tx of incomplete abortion, any trimester, completed surgically

59820

Tx of missed abortion, completed surgically; first trimester

59821

     second trimester

59830

Tx of septic abortion, completed surgically

59870

Uterine evacuation & curettage for hydatidiform mole


Background

Federal law (The Pregnancy Discrimination Act) requires any plan sponsored by an employer with more than 15 employees to cover pregnancy care. We are currently selling some plans that do not have pregnancy coverage.


Reference

Effective 01/01/2017: Codes added to ensure consistency of Medical and Claim Statements.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.