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SHBP/SEHBP Mandate on Early Elective Delivery

Effective January 1, 2021, State Health Benefits Program/School Employees’ Health Benefit Program members are not covered for costs associated with non-medically indicated early elective deliveries in accordance with established standards of clinical care as provided by the American College of Obstetricians and Gynecologists (ACOG). An Early Elective Delivery is defined as a scheduled cesarean section or medical induction performed prior to 39 weeks of gestation without any medical indication.

To determine if the claim meets ACOG standards, claims must include the patient’s gestational age
ICD-10 diagnosis code and a secondary diagnosis code to support the need for an early delivery. Claims that do not meet the ACOG standards will be denied.

Medical record documentation for each delivery service must include sufficient documentation to support all diagnosis codes and demonstrate the medical necessity of any early elective delivery.

The following two EOP/EOB message codes were implemented to specifically denote our processing for EED claims.

  • M228: Service is not covered under plan’s EED policy.
  • M229: No gestational age was submitted; please resubmit with the correct gestational diagnosis code.

The provider and/or member has the right to appeal claims denied with the above-noted codes or to submit corrected claim information for reconsideration.

If you have questions, please call your network specialist.

Published on: November 8, 2021, 23:55 p.m. ET
Last updated on: November 5, 2021, 03:36 a.m. ET