Provider Handbook

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Global maternity involves the billing process for maternity-related claims for a beneficiary. Once a beneficiary has been diagnosed as pregnant, all charges related to the pregnancy are grouped under one Global Maternity Diagnosis Code for the rendering professional provider.

Fig. 8.2

These diagnosis codes will be listed as the primary diagnosis when billing. Figure 8.2 lists examples of these codes.

When beneficiaries are referred for specialty OB care, prior authorization must be obtained for both outpatient and inpatient services.

Professional and technical components of medically necessary fetal ultrasounds are covered outside the maternity global fee. The medically necessary indications include (but are not limited to) clinical circumstances that require obstetric ultrasounds to: estimate gestational age, evaluate fetal growth, conduct a biophysical evaluation for fetal well being, evaluate a suspected ectopic pregnancy, define the cause of vaginal bleeding, diagnose or evaluate multiple gestations, confirm cardiac activity, evaluate maternal pelvic masses or uterine abnormalities, evaluate suspected hydatidiform mole, and evaluate the fetus’ condition in late registrants for prenatal care.

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The National Drug Code (NDC) number, drug quantity, and package unit (P/U) indicators are necessary on all injectables claims filings in order to ensure accurate pricing and payment of all injectables administered by providers.

EMC claims provide the fields for keying the NDC, drug quantity, and the package or unit indicator. This is all in addition to the HCPCS/CPT drug code and quantity which can be different from the NDC drug quantity. Where necessary, please provide supporting documentation such as the CMN, medical records, or NDC information. This can be submitted to PGBA through Faxgate and will be attached to the electronic claim.

CMS-1500 hard copy claims must use the shaded space above each line in the “Lines” field. These shaded areas are for additional information. The 11 digit NDC number (with no spaces or dashes), the drug quantity based on the NDC, and the “P” or “U” indicator should go in the shaded area. The actual line below the shaded area should include the appropriate HCPCS/CPT drug code and the quantity based on the code. Again, if supporting documentation (such as CMN, medical records, or NDC information) is needed, please include it with the submission of the paper claim.

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Designated providers are facilities specifically contracted with the Department of Defense to provide care to beneficiaries enrolled in the Uniformed Services Family Health Plan (USFHP). The USFHP is offered in six geographic regions in the United States. Although it provides the TRICARE Prime benefit, the USFHP is a separately funded program different than the TRICARE plan administered by Humana Military. The designated provider is at full risk for all medical care for a USFHP enrollee, including pharmacy services, primary care, and specialty care.

If you provide care to a USFHP enrollee outside the network or in an emergency situation, claims must be filed with the appropriate designated provider at one of the addresses listed in Figure 8.3. Do not file USFHP claims with Humana Military.
 

Fig. 8.3

Visit the US Family Health Plan Web site for more information about the USFHP.

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