Maternity Reimbursement

Reimbursement Policy
Maternity Reimbursement

Effective Date:
April 1, 2012

Last Revised Date:
July 23, 2015

Purpose:
This policy provides guidelines for Horizon BCBSNJ’s reimbursement methodology for NJ physicians in accordance with NJ State Law NJAC 11:22-9.1 et seq. PL 2009, c. 113. This policy applies to professional providers.

Scope:
All products are included except

• Products where Horizon is secondary to Medicare (i.e. Medigap).

• COB

All Insured and ASO accounts are included.

Policy:
Global Payments

All physicians who do not elect to receive maternity installment payments will be reimbursed for maternity services under one global procedure code, per pregnancy, that shall include: care occurring before childbirth (antepartum), all care and services related to the admission and management of labor & delivery, and routine care occurring after childbirth (postpartum) for a period of up to six weeks postpartum.

Installment Payments
In accordance with NJ State Law, as referenced above, all physicians who have formally submitted their election to be paid in maternity installment payments will be reimbursed in three (3) separate payments, each payment representing 1/3 of the global fee, to be reimbursed only once per pregnancy. Services included in these installment payments shall include: care occurring before childbirth (antepartum), all care and services related to the admission and management of labor & delivery, and routine care occurring after childbirth (postpartum) for a period of up to six weeks postpartum.

Site of service differentials will no longer apply to maternity codes to ensure the correct installment rate is applied.

In the event that multiple physicians are involved in the care of the patient, an adjustment will be performed where the installments will be paid at a percentage of the global fee.

Delivery and Postpartum Care Billed Separately
Horizon BCBSNJ will reimburse separately for delivery and postpartum care in the rare event that a different physician provides these services

Multiple Births
In instances of multiple births, Horizon BCBSNJ shall reimburse for one (1) global payment and a delivery only for each additional birth.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Global Payments
Horizon BCBSNJ shall reimburse only one (1) global procedure code per pregnancy.

Installment Payments
Horizon BCBSNJ shall reimburse installments payments at the same rate for each installment procedure code, with each installment representing 1/3 of the global fee, reimbursed only once per pregnancy.

In the event that multiple physicians are involved in the care of the patient, an adjustment will be performed where the installments will be reimbursed at a percentage of the global fee as follows:

• First Installment (Antepartum 4-6 visits) – 16%

• Second Installment (Antepartum 7 or more visits) – 30%

• Third Installment (Delivery & postpartum) – 54%

In instances where different physicians provide the delivery and postpartum care, Horizon BCBSNJ shall reimburse at a percentage of the global rate as follows:

• Delivery Only – 48%

• Postpartum Only – 6%

Multiple Births
Horizon BCBSNJ shall reimburse for one (1) global payment code/ third installment payment, respectively, and an additional delivery only code for each additional birth.

In instances of global and installment payments, Horizon BCBSNJ shall deny any prenatal, delivery and/or postpartum care billed separately, except in instances where a different physician provides the delivery and postpartum care.

Limitations and Exclusion:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group benefit

• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity

• Mandated or legislative required criteria will always supersede

CPT® is a registered trademark of the American Medical Association.

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