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TAOG Executive Office Karen O'Briant 141 Idlewild Creek Road Sweetwater, Texas 79556 (325) 235-1959 FAX: (325) 235-4687 TOLL FREE (866) 935-1959 TAOG 
E-mail
© Copyright 2001 Texas Association of Obstetricians & Gynecologists All Rights Reserved Photos by PhotoDisc |
| (5-26-10) URGENT UPDATE TO ALL TEXAS MEDICAID PROVIDERS: CHANGE IN ULTRASOUND POLICY.... |
You are here: Home > (5-26-10) URGENT UPDATE TO ALL TEXAS MEDICAID PROVIDERS: CHANGE IN ULTRASOUND POLICY....
Dear Texas Obstetrician:
We have been informed that on July 1, 2010, Texas Medicaid (Traditional Medicaid and Primary Care Case Management, not managed care Medicaid) will be implementing an Obstetrical Ultrasound Management Plan.
• 3 ultrasounds allowed per 280 days (beginning on July 1, the computer will count backwards 280 days)
• After 3 ultrasound examinations (even if by another doctor), a prior authorization is required
• The prior authorization can be by telephone, fax, or TMHP’s website portal
• Medicaid’s policy mirrors the indications for ultrasound based on ACOG Practice Bulletin No. 101. However, it is recognized that this may not be an all-inclusive list, so ultrasounds for other indications will be considered based on demonstration of medical necessity
• You have 14 calendar days from the time the ultrasound was performed until you must submit a request for prior authorization
• Prior authorization must be requested prior to the submission of a claim
• Starting July 1st , for one-time only, there will be a 60 day grace period during which retroactive authorization can be submitted for those claims that were denied for lack of prior authorization
• Thereafter, the appeal process can be initiated for claims denied for lack of prior authorization (see next bullet)
• If an ultrasound was denied for lack of prior authorization and (1) it is a new pregnancy within 280 days OR (2) your office was unable to obtain previous ultrasound records from a different physician OR (3) the patient was new to your practice and you were not aware the patient had already received 3 OB ultrasounds, you may submit an appeal with documentation that supports one of these conditions existed
• This appeal process may only be invoked once. All ultrasounds thereafter will require prior authorization
• TMHP Website: www.tmhp.com
• This ultrasound management plan does not affect those ultrasounds performed or interpreted in the hospital emergency department, Hospital OB Triage areas, during an observation on labor and delivery or in the course of an inpatient hospitalization. It is very important also for your staff to use the U6 modifier when ultrasounds are billed in the ED or during an outpatient observation so that they will not be counted toward the limit of three or be denied for lack of prior authorization
Recommendations:
• Please be familiar and have your billing person be familiar with this new prior authorization process for OB (not gyn) ultrasounds
• Please check your denials regularly for ultrasound studies
• Please forward any suggestions or comments to TAOG, as we have a physician consultant stakeholder group that meets with Texas Medicaid on an ongoing basis. Forward comments to me at ectoy@tmhs.org, or taog@hotmail.com.
Sincerely,
Eugene C. Toy, MD
President, Texas Association of Ob/Gyn
Chair, Section 4 District XI ACOG
1819 Crawford Street, Suite 1708
Houston, TX 77002
ectoy@tmhs.org
713-756-5616
A LINK TO THE TMHP BULLETIN IS PROVIDED BELOW:
TMHP July-Aug Texas Medicaid Bulletin #230