Women's health programs and policies - Aetna

 
Women's health programs and policies - Aetna
Women’s health programs and policies

22.20.800.1 A (9/17)
                           aetna.com
Women's health programs and policies - Aetna
Women’s
    health
    programs
          This manual will help you
          understand our women’s
          health programs and policies.

          And we’ll be right there
          with you, throughout all
          of life’s stages.

    Aetna is the brand name used for products and services provided by one or more of the Aetna group of
    subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).
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Women's health programs and policies - Aetna
Table of contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4                 Obstetric policies and reimbursement . . . . . . . . 15
Key phone numbers and contacts . . . . . . . . . . . . . . . . . . 5                             Global obstetric fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Online resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5             Perinatology services . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
                                                                                                 Reproductive genetic counseling . . . . . . . . . . . . . . . . . 19
Gynecologic programs, policies                                                                   Rh immune globulin policy . . . . . . . . . . . . . . . . . . . . . . . 19
and reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . 7                          Flu vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Primary and preventive gynecologic services . . . . . . . . 7                                    Postpartum visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
   Direct-access/prior authorization policies . . . . . . . . . 7                                Non-emergency, non-obstetric medical care . . . . . . . 19
   Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7   Spontaneous abortions . . . . . . . . . . . . . . . . . . . . . . . . . 20
Radiology services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7             Instructions for billing portions of prenatal care
Automatic studies for gynecologic services . . . . . . . . . . 7                                  and delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Cervical cancer screening services . . . . . . . . . . . . . . . . . . 7                         High-risk pregnancy management enhancement . . . 20
  Human papillomavirus (HPV) DNA screening . . . . . . . 7                                       Cell-free fetal nucleic acid screening . . . . . . . . . . . . . . 20
Breast health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8        First and second trimester non-invasive screening
 Referral policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8            to provide individual risk assessment for
 Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8                fetal aneuploidy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
 Breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8         Credentialing requirements for fetal aneuploidy
BRCA: genetic testing for breast and ovarian cancer . . . 8                                       screening involving nuchal translucency (NT)
  How to get BRCA testing approval for a member . . . 8                                           measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Genetic counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9               Other services covered for individual risk
Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9           assessment for fetal aneuploidy . . . . . . . . . . . . . . . . . 22
Capitated lab services for women’s health services . . . 9                                       Intramuscular progesterone therapy . . . . . . . . . . . . . . 22
HPV DNA testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9              Home births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
HPV vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Infertility program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10             Frequently asked questions . . . . . . . . . . . . . . . . . 23

Beginning Right® maternity program . . . . . . . . . . 11                                        Other online resources . . . . . . . . . . . . . . . . . . . . . . 26
Member eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Member enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Program content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
 Welcome packet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
 Second trimester educational mailing . . . . . . . . . . . . . 11
 Third trimester educational mailing . . . . . . . . . . . . . . . 11
Pregnancy risk survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Case management of high-risk-pregnancy activities . . 12
Preterm labor education program . . . . . . . . . . . . . . . . . 12
 Beginning Right follow-up . . . . . . . . . . . . . . . . . . . . . . . 12
African American preterm labor education program . . 12
Smoke-Free Moms-to-Be® smoking
 cessation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Pregnancy and postpartum depression screening . . . 13
Diabetic case management for pregnant members . . 13
Other important notes . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
 Getting obstetric care . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
 Prenatal care access standards . . . . . . . . . . . . . . . . . . . 14

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Women's health programs and policies - Aetna
Introduction

    Women’s health programs are        This manual will help you understand our women’s
                                       health programs and policies. Some of the programs
    an important part of our           may not be available to members who select a primary
    medical management efforts.        care physician (PCP) affiliated with an independent
                                       practice association (IPA), physician medical group,
                                       integrated delivery system or other provider group.

    We offer programs that             To determine eligibility, just contact us at the phone
                                       number listed on the member’s Aetna ID card.
    facilitate a holistic member       We let you know about changes in policy through:
    view, consider multiple diseases   • Our Aetna OfficeLink Updates™ newsletter
    and conditions across all          • Our public website at aetna.com
    benefits plans and deliver         • Our secure provider website on NaviNet® at
    individualized programs based        https://navinet.navimedix.com.

    on a member’s unique needs
    and preferences.

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Women's health programs and policies - Aetna
Before you access the information in this manual, review       Key phone numbers and contacts
these important highlights:
                                                               • Beginning Right maternity program
• Patient advocacy — Physicians are advocates on                 1-800-272-3531
  behalf of their Aetna patients. Read the “Member Rights      • Infertility case management program
  and Responsibilities” section of our Office Manual for         1-800-575-5999
  Health Care Professionals. You’ll find it at
                                                               • Breast Health Education Center
  https://navinet.navimedix.com.
                                                                 1-888-322-8742
• Informed consent — Physicians are responsible for
                                                               • BRCA genetic testing program
  providing their patients with all information relevant to
                                                                 1-877-794-8720
  their condition(s). This includes all health care
  alternatives, even if an option isn’t covered by their       • Provider Services
  plan, as well as potential risks and benefits of each.        - HMO-based and Medicare plans: 1-800-624-0756
• Patient emergencies — If our members need                     - All other plans: 1-888-MD-Aetna (1-888-632-3862)
  emergency care, they’re covered 24 hours day, 7 days
  a week, anywhere in the world.                               Online resources
• Providing medical information — Physicians are               • Women’s health information — Visit the “Individuals
  responsible for giving us the complete and accurate            & Families” section of aetna.com. Then, under
  medical information required (that is, diagnosis, clinical     “Information & Resources,” click “Women’s Health.” Here
  information and/or services provided) to make                  you’ll find general women’s health information and
  appropriate coverage determinations.                           details on women’s health programs.
• Independent contracting — As indicated in all of our          Topics include:
  provider agreements, participating providers aren’t           - Advice for moms-to-be
  employees or agents of any Aetna affiliate.
                                                                - Understanding and treating breast and
• Information about coverage — If you’re unsure if                ovarian cancers
  a particular service is covered under a member’s plan,
                                                                - Helpful tips for every stage of a woman’s life
  contact us using:
                                                               • Our secure provider website — Search for
 - Our secure provider website at
                                                                 physicians, hospitals and other health care
   https://navinet.navimedix.com
                                                                 professionals at https://navinet.navimedix.com.
 - Our dedicated Provider Service Centers — for                  You can also access the site at aetna.com. Under
   health maintenance organization (HMO)-based and               “Health Care Professionals,” click “Secure Provider
   Medicare plans, 1-800-624-0756; for all other                 Website.” Once on the site, register or log in with
   plans, 1-888-MDAetna (1-888-632-3862)                         your user name and password. Features of this
• Appeals — You may appeal adverse benefits                      website include:
  determinations and provider reimbursement decisions.          - Online professional claims submission
  Also, members and some physicians may have the                  (HCFA/CMS 1500) for physicians and
  right to an external review if the circumstances of the         physician groups
  appeal meet certain criteria. To find out more about
  our dispute and appeal process, just go to the “Health
  Care Professionals” section at aetna.com. Then click
  “Dispute & Appeal Process.”

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Women's health programs and policies - Aetna
- Data-entry screens for online claim inquiries         • Pharmacy services and tools — Visit the “Health
       and eligibility, and real-time referral and             Care Professionals” section at aetna.com. Then under
       precertification transactions                           “Products & Programs for Health Care Professionals,”
     - Online electronic remittance advice/electronic          click on “Pharmacy Services.” Here you’ll find
       funds transfer (ERA/EFT) enrollment form                information on:
     - The ability to update your office profile              - Aetna Specialty Pharmacy ® medicine and support
                                                                services including medication ordering, shipping
     - Information on automatic studies
                                                                and delivery
     - The Office Manual for Health Care Professionals
                                                              - Our formulary
    • Clinical Policy Bulletins — Go to aetna.com.
                                                              - Pharmacy Clinical Policy Bulletins
    • Preventive services guidelines — Go to our secure
                                                             • Aetna BRCA Precertification Information Request
      provider website at https://navinet.navimedix.com.
                                                               Form — To get the form:
      After logging in, choose “Aetna Health Plan” under
      “My Health Plans.” Then go to Support Center >          - Visit the “Health Care Professionals” section at
      Clinical Resources > Preventive Services Guidelines.      aetna.com. Then go to Resources for Health
                                                                Care Professionals > Forms > Medical Precertification.
                                                              - Call us at 1-800-624-0756.

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Gynecologic programs,
policies and reimbursement
Primary and preventive                                      In areas where radiology services are capitated, the
gynecologic services                                        member should be referred to the capitated site
(HMO, Aetna Health Network OnlySM plans and                 associated with her PCP.
Aetna Health Network OptionSM plans)                        For capitated radiology centers in the area, members
                                                            should contact their PCP or call the number on their
Direct-access/prior authorization policies
                                                            Aetna member ID card.
Our direct-access obstetrics and gynecology policy
covers services provided by a member’s obstetrician/
                                                            Automatic studies for gynecologic services
gynecologist (Ob/Gyn) without a referral from her primary
                                                            (HMO, Aetna Health Network Only plans and
care physician (PCP). A woman may also elect to have her
                                                            Aetna Health Network Option plans)
PCP perform her annual primary health care exam.
                                                            Automatic studies are services for which we pay
The Ob/Gyn should tell the member’s PCP about the
                                                            providers when the services are performed in the
services and treatment plan developed as a result of any
                                                            specialist’s office, regardless of whether the procedure
direct-access visits.
                                                            itself was specifically indicated on the referral.
In some areas, the Ob/Gyn may function as the
                                                            In general, these are procedures that are critical to the
member’s PCP and may refer the member to any
                                                            evaluation of the problem that led to the referral to
participating provider, including specialists, for any
                                                            the specialist.
covered, medically necessary services. For more
information, call us at 1-800-624-0756.                     Inclusion of a study on the automatic studies list doesn’t
                                                            guarantee payment. Rather, we’ll pay according to our
Billing                                                     standard processing guidelines.
The annual gynecologic primary and preventive visit
should be billed using the E&M codes for preventive         To see a list of automatic studies for Ob/Gyns, go to
visits (99384 – 99387 and 99394 – 99397).                   https://navinet.navimedix.com.

All other visits should be coded using standard             After logging in, select “Aetna Health Plan” under
E&M codes.                                                  “Plan Central,” then “Referrals” and “Automatic Studies
                                                            by Specialty.”
Your office should collect the appropriate copayment
from the member for these services. Refer to the            Cervical cancer screening services
member’s ID card for copayment information.
                                                            Human papillomavirus (HPV) DNA screening
Radiology services                                          We cover HPV DNA screening with either conventional
(HMO, Aetna Health Network Only plans and                   Pap smears or liquid-based cytology for primary cervical
Aetna Health Network Option plans)                          cancer screening of women ages 30 and older, when not
                                                            otherwise excluded by the member’s benefits plan.
Gynecology ultrasounds (for example, CPT codes 76830,
                                                            Women who receive negative results on both tests
76831, 76856 and 76857) may be performed in the
                                                            should be rescreened no more frequently than every
Ob/Gyn office without a referral or prior authorization
                                                            three years. This policy is consistent with guidelines
and are reimbursed on a fee-for-service basis.
                                                            from the American Congress of Obstetricians and
If the Ob/Gyn doesn’t provide office-based gynecology       Gynecologists (ACOG) (2014).
ultrasounds, members should be referred to a
                                                            HPV DNA testing in women younger than age 30
participating radiology center with a valid
                                                            isn’t a covered benefit for primary cervical cancer
physician’s order.
                                                            screening. Again, this policy is consistent with ACOG
                                                            guidelines (2014).

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For more information, refer to Clinical Policy Bulletin      For more information about the Breast Health Education
    #0443. See our Clinical Policy Bulletins at aetna.com.       Center, call 1-888-322-8742 from 8:00 a.m. to
    Or find them on our secure provider website at               4:30 p.m. ET.
    https://navinet.navimedix.com.
                                                                 BRCA: genetic testing for breast and
    Breast health
                                                                 ovarian cancer
    (all products)
                                                                 (all products)
    Referral policies                                            Confidential molecular susceptibility testing for breast
    Members have direct access to gynecologists who,             and/or ovarian cancer (BRCA testing) is covered for
    in addition to providing routine care, may authorize         members who meet medical appropriateness criteria.
    referrals for specialty care for related services.           All BRCA testing must be precertified.
    Gynecologists may refer members for consultations
    (which include automatic studies) to the following           For more information, refer to Clinical Policy Bulletin
    specialties without a primary care physician                 #0227. Access our Clinical Policy Bulletins on our public
    (PCP) referral:                                              website at aetna.com. Or find them on our secure
                                                                 provider website at https://navinet.navimedix.com.
    • Breast surgery
                                                                 We may also cover BRCA testing for non-Aetna members
    • General surgery
                                                                 when the information is needed to adequately assess
    • Gynecologic oncology                                       risk in the Aetna member and the non-member doesn’t
    • Oncology                                                   have other coverage for this testing. Such coverage
    • Urology                                                    requires prior authorization and is subject to the terms
                                                                 of the subscriber’s benefits plan.
    • Urogynecology

    Mammography                                                  How to get BRCA testing approval for a member
    Members have direct access for mammography services          According to our Clinical Policy Bulletin #0227, all BRCA
    at contracted radiology facilities. A referral isn’t         testing must be precertified. We have a national network
    necessary. For the provider to be reimbursed properly,       of contracted providers that offer BRCA services. They
    the member must present a valid physician’s order to a       also offer a support network of genetic counselors who
    participating radiology facility.* In areas with capitated   are experts in inherited cancers. And they can help you
    radiology arrangements, you should send members to           select the right BRCA test. You’ll find these providers
    the capitated site associated with their PCP.                listed in our online directory at aetna.com.

                                                                 To get approval for BRCA testing:
    Breast cancer
    Our Breast Health Education Center (available to HMO,        1. Complete our BRCA Precertification Information
    Aetna Health Network Only and Aetna Health Network              Request Form and fax it to us at 860-975-9126 for
    Option plan members only) identifies members who                review and approval.** You’ll find the form at
    have been newly diagnosed with breast cancer within             aetna.com > Health Care Professionals > Resources
    the prior year and offers services to help them make            for Health Care Professionals > Forms > Medical
    informed choices about their treatment and recovery.            Precertification. A list of our contracted providers is
    Members can fill out a breast survey on their secure            on the form.
    member website to be referred to the center. Members
                                                                 2. Fill out the contracted provider’s testing request form.
    participating in the program may get:
                                                                    To get the form, contact the provider.
    • Personalized nurse care coordination
    • Education about breast cancer

     *Members with HMO-based plans in Alaska, Florida and Louisiana may require referrals for all radiology services
      provided in hospital-based radiology settings. Mammography services (CPT codes 77061, 77062, 77063, 77065,
      77066, 77067) may be performed in an Ob/Gyn office without a referral or prior authorization and be reimbursed
      on a fee-for-service basis.
    **Completion of an Aetna BRCA Precertification Information Request Form doesn’t guarantee payment.
      Payment of covered benefits is subject to the provider’s contract, the member’s eligibility on the dates
      of services rendered and specific provisions of the member’s health benefits plan.
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3. If we approve testing, send our BRCA Precertification          Capitated lab services for women’s
   Information Request Form, the contracted provider’s            health services
   testing request form and the member’s specimen to              (HMO, Aetna Health Network Only plans
   the contracted provider.                                       and Aetna Health Network Option plans)
4. There is an “Other” category on our BRCA                       Refer Aetna members to our network lab providers,
   Precertification Information Request Form. This is             like Quest Diagnostics, for covered services.
   for women who don’t meet any criteria listed but
   or whom it’s been determined (through both                     If you refer an Aetna member to an out-of-network lab,
   independent formal genetic counseling and                      you must tell them you’re doing so and document the
   quantitative risk tool assessment) to have at least a          out-of-network referral. They must understand and
   10 percent pretest probability of carrying a BRCA1             accept the possibly higher costs.
   or BRCA2 mutation. For this category only, fax                 Covered lab studies include but aren’t limited to:
   a three-generation pedigree and formal genetic
   counseling and quantitative risk assessment                    • Beta hCG
   results directly to us at 860-975-9126.                        • Glucose screening
                                                                  • Prenatal panel
For more information, leave a message for us at
1-877-794-8720. We’ll call you back as soon as possible.          • Serum analyte tests for aneuploidy screening in
                                                                    pregnancy (see Clinical Policy Bulletin #0464)
Genetic counseling                                                • Cell-free DNA testing (see Clinical Policy Bulletin #0464)
                                                                  • Cytogenetic studies
Face-to-face and telephonic genetic cancer counseling
are available. These services are available without a             • Cystic fibrosis carrier testing (see Clinical Policy
referral from the member’s PCP.                                     Bulletin #0140)
                                                                  • Basic infertility screening labs (see Clinical Policy
For a list of our contracted genetic counseling providers,
                                                                    Bulletin #0327)
including our telephonic provider, InformedDNA, see our
online provider directory. Just go to the “Health Care            • Sexually transmitted diseases (see Clinical Policy
Professionals” section at aetna.com. Then click on                  Bulletin #0433)
Helpful Links > Online Provider Directory. If you want            • Cervical cancer screening, cytology and
InformedDNA, type the word “Genetics” into the Search               HPV testing
box. Enter a city or ZIP code. Click “Enter.” The first listing   You can see our Clinical Policy Bulletins on our public
will be “Genetic Conditions.” Click on it.                        website at aetna.com. Or find them on our secure
For more information about genetic cancer counseling              provider website at https://navinet.navimedix.com.
through InformedDNA, call 1-800-975-4819 or go to
informeddna.com.                                                  HPV DNA testing
Members affiliated with IPAs must get approval through            Routine cervical cancer screening isn’t recommended
their IPA prior to using telephonic genetic counseling.           until after age 21. When not otherwise excluded by the
                                                                  member’s benefits plan, we cover primary HPV DNA
Contraception                                                     screening with either conventional Pap smears or
(HMO, Aetna Health Network Only plans                             liquid-based cytology for primary cervical cancer
and Aetna Health Network Option plans)                            screening of women ages 30 and older.

To determine coverage, call us at 1-800-624-0756.                 ACOG recommends that women over age 30 who
                                                                  have both a normal Pap smear and no evidence of
                                                                  HPV infection be screened for cervical cancer no more
                                                                  frequently than every three years. Our clinical policy
                                                                  or cervical cancer screening coverage is consistent
                                                                  with these recommendations.

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HPV testing is covered as a reflex or triage test that         The vaccine is a series of three shots for women
     follows a Pap smear laboratory result of atypical              13 to 26 years of age, if not previously vaccinated at
     squamous cells of undetermined significance in women           11 or 12 years of age.
     of any age, including women younger than 30 years of
                                                                    For more information, see Clinical Policy Bulletin #0443.
     age. It may also be covered as a follow-up when there
                                                                    You can access our Clinical Policy Bulletins on our public
     are abnormal histologic results, consistent with the
                                                                    website at aetna.com. Or find them on our secure
     guidelines of the American Society for Colposcopy and
                                                                    provider website at https://navinet.navimedix.com.
     Cervical Pathology.

     For more information, see Clinical Policy Bulletin #0443.      Infertility program
     You can see our Clinical Policy Bulletins at aetna.com.
     Or find them on our secure provider website at                 Our National Infertility Unit helps eligible members
     https://navinet.navimedix.com.                                 coordinate covered treatment-level infertility and
                                                                    infertility-related genetic testing (preimplantation
     More information on cervical cancer screening                  genetic testing) services and provides them with
     recommendations is available through the                       information and guidance. The program is staffed by
     following websites*:                                           registered nurses, licensed practical nurses and
                                                                    infertility coordinators with expertise in infertility.
     • American Cancer Society
       cancer.org                                                   To determine a member’s eligibility, call the phone
     • American Congress of Obstetricians and Gynecologists         number listed on the member’s ID card.
       acog.org
                                                                    Members who wish to access infertility benefits offered
     • American Society for Colposcopy and                          under their plan should call us at 1-800-575-5999.
       Cervical Pathology                                           We’re here from 8 a.m. to 5 p.m. ET (7 a.m. to 3 p.m. PT).
       asccp.org
                                                                    Coverage may vary due to state mandates requiring
                                                                    infertility coverage and optional infertility riders
     HPV vaccine                                                    available to employer groups with over 500 members.
     We consider a quadrivalent HPV (types 6, 11, 16, 18)
                                                                    For more information, including the registration
     recombinant vaccine for cervical cancer a medically
                                                                    form, go to the “Individuals & Families” section on
     necessary preventive service for males and females
                                                                    aetna.com. Then under “Information &
     from 9 to 26 years of age.
                                                                    Resources,” select “Women’s Health,” then click
                                                                    “Learn more about infertility and its treatment.”

     *Inclusion of these organizations and websites does not constitute an endorsement by Aetna of the
      organizations nor their websites, and Aetna has no responsibility for the accuracy or currency of the content
      of the websites.
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Beginning Right® maternity program

The goal of the Beginning Right maternity program is to       Second trimester educational mailing
help members and providers achieve a healthy term             Members get an educational mailing at 14 weeks’
delivery. It provides educational materials, and eligible     gestation. This includes information about:
members receive case management throughout
their pregnancies.                                            • Signs and symptoms of preterm labor
                                                              • High-risk pregnancy conditions
Member eligibility
                                                              Third trimester educational mailing
The Beginning Right program is available to most              During their eight month, members get an educational
pregnant HMO-based plan members. Members of other             packet. It includes information about the timing of
health benefits plans may be eligible to participate in the   delivery and postpartum concerns:
program, depending on the individual employer-
                                                              • Waiting for Baby educational video at aetna.com/
sponsored plan. To see if a member is eligible for the
                                                                individuals-families/womens-health/pregnancy­
program, call the number listed on the member’s
                                                                information-video.html
Aetna card.
                                                              • Information on the need for a postpartum visit four to
Member enrollment                                               six weeks after delivery
                                                              • Brochure with helpful guidance for the mother and
To begin the program enrollment process or learn more
                                                                health tips for the baby
about the program, call us at 1-800-272-3531. Members
                                                              • Immunization schedule for healthy infants and
can also enroll via their member website. Once on the
                                                                children, based on guidelines from the Centers for
site, members should go to “Information & Resources”
                                                                Disease Control and Prevention (CDC) Advisory
then “Women’s Health.”
                                                                Committee on Immunization Practices

Program content                                               • Procedures for adding a newborn to the member’s
                                                                health plan coverage
We’ll provide members with educational materials
throughout their pregnancy, including:

Welcome packet
After enrolling in the program, the membes get a
welcome packet that includes information about:

• Normal pregnancies
• Prenatal care
• Dental health
• High-risk pregnancy conditions
• Postdelivery care
• Postpartum depression
• Newborn care

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Pregnancy risk survey                                         members identify preterm labor. Program components
                                                                   may include one or more of these:
     To enroll in the program, members must first complete a
     pregnancy risk survey. This survey identifies risk factors    • Education about the signs and symptoms of preterm
     that may complicate a member’s pregnancy and for                labor by trained obstetric nurses
     which we provide additional services.                         • A home nurse visit (if available in her area) to review
     We assign a nurse case manager to members with                  the symptoms of preterm labor and teach how to
     certain high risk factors. The extent of time and               palpate for contractions
     involvement of the case manager depends on the risk           • Continued care coordination by a Beginning Right
     factor and the chronicity of the problem.                       program nurse case manager if preterm labor occurs

     We provide case management for these risk factors:            Beginning Right follow-up of members requiring
                                                                   17 alpha-hydroxyprogesterone caproate (17P) for
     • Pregnancy-induced hypertension or chronic                   a previous preterm birth
       hypertension
                                                                   Members who self-inject with 17P will be contacted
     • Type 1 or 2 diabetes or gestational diabetes                weekly by a Beginning Right nurse case manager during
     • Hyperemesis (during acute treatment phase only)             the first month of treatment and monthly until delivery.
     • Women at risk for preterm birth, including those with       They’ll contact all others the first week to verify start
       a prior preterm delivery, women in the extremes of          date and then monthly until delivery.
       reproductive age (younger than 19 and older than
       40 years) and African American women                        African American preterm labor
     • Active preterm labor                                        education program
     • Multiple gestation                                          Preterm birth rates were nearly 48 percent higher
     • Smoking                                                     among black women compared to white women.1
     • History of postpartum depression or depression
                                                                   For this reason, we developed a comprehensive preterm
     • Others not listed                                           labor education and support program targeting
                                                                   pregnant African American members.
     Case management of high-risk­
     pregnancy activities                                          The primary goals of the program are to:
     Nurses provide education and outreach focused on the          • Improve member and physician awareness of the
     high-risk factors we identify. Activities may include:          increased risk of premature birth for African
     • Collaboration with obstetric providers to                     American women
       coordinate care                                             • Implement member education programs that increase
     • Review of signs and symptoms of preterm labor during          member knowledge of how and when to best access
       each member contact                                           care and participate in treatment decisions
     • Specialized education and medically indicated home          Program components offered to all self-identified
       care services, including:                                   African American pregnant members include:
         - Preterm labor education program                         • Educational information on preterm birth
         - Smoke-Free Moms-to-Be® smoking
                                                                   • Telephone outreach at 24 weeks’ gestation by a
           cessation program
                                                                     clinician nurse to offer enrollment in the preterm labor
     Preterm labor education program                                 education program
                                                                   • A home nurse visit, if available in the member’s area, to
     Pregnant members identified through the pregnancy
                                                                     review the signs and symptoms of premature labor and
     risk survey as being at risk for preterm labor (or whose
                                                                     instructions on how to self-palpate for contractions
     physician requests certain services) are offered
                                                                   • Periodic calls from Beginning Right nurse case
     enrollment in the preterm labor education program.
                                                                     managers to review signs and symptoms of
     This is if their plan offers home health care benefits.
                                                                     preterm labor
     The program provides educational instruction to help

     March of Dimes, 2016 Premature Birth Report Cards. Preterm birth increases in the U.S. for the first time
     1

     in eight years. September 20, 2017.
12
Smoke-Free Moms-to-Be smoking                             postpartum outreach is completed three to five
cessation program                                         weeks postdelivery and then again three to four
                                                          months postdelivery.
If a pregnant member indicates on the pregnancy risk
survey that she smokes, we’ll offer her the chance to     We offer women who screen as positive for antenatal or
participate in Smoke-Free Moms-to-Be, our nicotine-free   postpartum depression access to an appropriate Aetna
smoking cessation program. This program includes:         Behavioral Health provider. Or we refer to their obstetric
                                                          care provider if they don’t have behavioral health
• An educational brochure                                 benefits. Where applicable, we provide access to
• A cigarette substitute                                  Aetna Behavioral Health med/psych case managers.
• Contact with a Beginning Right nurse case manager       Other behavioral health programs or providers are
  throughout the pregnancy                                also available.

Pregnancy and postpartum                                  Diabetic case management for
depression screening                                      pregnant members
The Beginning Right maternity program, working with       Beginning Right nurse case managers:
Aetna Behavioral Health, has developed a pregnancy
                                                          • Work with the obstetric care provider to coordinate
and postpartum depression screening program.
                                                            diabetic education and nutritional counseling
This program aims to reduce the severity, duration and    • Consult with a perinatologist or endocrinologist for
impact of depression during and after pregnancy. The        diabetes management
program uses a depression screening tool to help
                                                          • Generate any prior authorizations that the member’s
identify members who may be at risk for depression.
                                                            plan requires.
The antenatal depression screening is included on all
pregnancy risk surveys performed by phone or during
the first phone contact with members who complete the
pregnancy risk survey on their member website at
aetna.com. The postpartum screening is done for
all members who qualify for these calls. The first

                                                                                                                       13
Other important notes                                        While there may be times during which appointment
                                                                  availability may not meet these standards, an office
     Getting obstetric care                                       must generally be able to keep this degree of access. In
     Members with a positive pregnancy test (either home          group practices, members should be offered the option
     urine pregnancy test or blood test) can get obstetric        of seeing another provider in the office if an individual
     care directly, without written prior authorization from      physician can’t meet the above standards.
     a PCP.
                                                                  If, for any reason, your office won’t be able to offer this
     Though precertification of delivery isn’t required, we ask   level of appointment availability (other than the
     obstetric care providers to call the Beginning Right         emergency standard) for more than four consecutive
     maternity program at 1-800-272-3531 to begin the             weeks, call us at 1-800-624-0756 as soon as possible.
     program enrollment process. To enroll in the program,
                                                                  The Beginning Right maternity program is subject to
     members must complete the pregnancy risk survey.
                                                                  change without notice. Certain features may not apply
     Please tell members that they must call the
                                                                  in all cases.
     Beginning Right maternity program or log in to their
     member website at aetna.com to take the survey and           Not all programs are available to all members. Call
     complete the enrollment process.                             the number listed on the member’s ID card to find
                                                                  out if a particular patient is eligible to participate in
     Enrollment in the program will entitle all eligible
                                                                  this program.
     members to get:

     • Educational materials in English or Spanish
     • The opportunity to complete a pregnancy risk survey
     • Nurse case management if they are identified by the        Call the Beginning Right
       pregnancy risk survey to be at risk for certain medical    maternity program at
       conditions, such as preterm birth, chronic
       hypertension or gestational diabetes                       1-800-272-3531 to:
     • Access to our smoking cessation program
     Members who enroll in the Beginning Right program            • Register eligible members
     before 16 weeks’ gestation receive a gift.
                                                                  • Access case management
     Prenatal care access standards
     Appointments for routine obstetric visits and urgent
                                                                    services
     conditions must be available to members within               • Learn more about
     reasonable time frames.
                                                                    the program
     We’ve adopted the following standards for prenatal care
     appointment availability:

       First visit for          Within three weeks in the
       obstetric care           first trimester; within two
                                weeks in the second or third
                                trimesters

       Urgent visits            Within 24 hours

       Postpartum visit         Four to six weeks
                                after delivery

14
Obstetric policies and reimbursement

Global obstetric fee                                           Reimbursement for obstetric ultrasounds remains on a
(HMO, Aetna Health Network Only plans and                      fee-for-service basis for members enrolled in indemnity
                                                               and preferred provider organization (PPO)-based plans.
Aetna Health Network Option plans)
                                                               Note: We don’t require prior authorization from the
Services reimbursed outside of the global obstetric
                                                               Beginning Right maternity program for a pregnant
fee include:
                                                               member’s routine laboratory studies if done at the
Inpatient visits provided for the below are considered         capitated laboratory associated with the member’s PCP.
part of the global obstetric fee and are not subject to        Or if there’s no capitated laboratory, at any participating
payment on a fee-for-service basis:                            laboratory in the network.

• The day before delivery                                      The national laboratories provide a full range of
• The three postpartum days for vaginal delivery               laboratory services, including cystic fibrosis screening,
                                                               cytogenic studies and other genetic services.
• The five postpartum days for cesarean delivery

Amniocentesis, chorionic villus sampling and biophysical
profiles are reimbursed on a fee-for-service basis.

Office visits and ultrasounds performed by the obstetric
care provider on members presumed to be pregnant
(based on a previous pregnancy test) who are found not
to be pregnant are reimbursed on a fee-for service
basis. Submit a claim for the office visit using the correct
ICD code for the unconfirmed pregnancy.

                                                                                                                             15
Perinatology services
     On the next two pages, you’ll find some of the more                  A referral from the Ob/Gyn or PCP to the perinatologist
     frequently used services that a perinatologist performs.             is required for: Aetna SelectSM EPO plans, Elect Choice®
     These services don’t require prior authorization. But                plans, HMO plans, Managed Choice® POS and Quality
     they may require evidence of medical appropriateness                 Point-of-Service® plans. Referrals can be done
     as a condition of reimbursement.                                     through our secure provider website at
                                                                          https://navinet.navimedix.com.

     Procedure CPT codes                         ICD codes considered medically             Comments
                                                 appropriate

     Consultations: 99241 – 99245                640.00 - 676-94 = O20.0 - O92.70
                                                 V23 - V23.9 = O09.0 - O09.93,
     Office visits: 99201 – 99205 and 99211      V28.2 = Z36, V28.4 = Z36
     – 99215

     Routine fetal ultrasounds: 76801, 76802,    See Clinical Policy Bulletin #0199
     76805, 76810, 76815, 76816, 76817,          for ICD codes.
     NT76813 and NT76814

     Detailed fetal ultrasounds: 76811, 76812    See Clinical Policy Bulletin #0199         One detailed fetal ultrasound (CPT code
                                                 for ICD codes.                             76811) per member, per pregnancy, per
                                                                                            practice is covered.

                                                                                            Any follow-up of 76811 should be billed
                                                                                            with another CPT code.

     Genetic counseling: 99243                   640.00 - 676-94 = O20.0 - O92.70
                                                 V23 - V23.9 = O09.0 - O09.93,
                                                 V28.2 = Z36, V28.4 = Z36

     Nuchal translucency (NT) testing:           See Clinical Policy Bulletins #0199        ACOG recommends the following for
                                                 and #0464 for ICD codes.                   NT screening:
     • 76813: Nuchal translucency testing
     • 76814: Nuchal translucency testing each                                              1. Appropriate ultrasound training and
       additional gestation                                                                    ongoing quality monitoring programs
     • 84704: hCG free Beta                                                                    are in place.
     • 84163: PAPP A                                                                        2. Sufficient information and resources
     • 82105: AFP                                                                              are available to provide comprehensive
     • 84702: hCG quantitative                                                                 counseling to women regarding the
                                                                                               different screening options and
                                                                                               limitations of these tests.

                                                                                            3. Access to an appropriate diagnostic
                                                                                               test is available where screening test
                                                                                               results are positive.

     Cell-free DNA testing:                      See Clinical Policy Bulletin #0464
     81420                                       for ICD codes.

     Amniocentesis: 59000                        640.00 - 676-94 = O20.0 - O92.70           Amniocentesis based on patient demand
                                                 V23 - V23.9 = O09.0 - O09.93, V28.2 =      is covered.
     Ultrasound guidance for amniocentesis:      Z36, V28.4 = Z36
     76946

16
17
Procedure CPT codes                     ICD codes considered medically          Comments
                                             appropriate

     Chorionic villi sampling (CVS): 59015   640.00 - 676-94 = O20.0 - O92.70        CVS based on patient demand
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =   is covered.
     CVS with ultrasound guidance: 76945     Z36, V28.4 = Z36

     NST: 59025                              640.00 - 676-94 = O20.0 - O92.70
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

     Biophysical profile (BPP): 76818        640.00 - 676-94 = O20.0 - O92.70
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

     BPP without NST: 76819                  640.00 - 676-94 = O20.0 - O92.70
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

     Fetal echocardiograms: 76825, 76826,    See Clinical Policy Bulletin #0106      Services must meet medical
     76827, 76828, 93325                     for ICD codes.                          appropriateness edits described in
                                                                                     Clinical Policy Bulletin #0106.

     Fetal umbilical artery Doppler: 76820   See Clinical Policy Bulletin #0106      Services must meet medical
                                             for ICD codes.                          appropriateness edits described in
                                                                                     Clinical Policy Bulletin #0106.

     Middle cerebral artery Doppler: 76821   See Clinical Policy Bulletin #0106      Services must meet medical
                                             for ICD codes.                          appropriateness edits described in
                                                                                     Clinical Policy Bulletin #0106.

     Percutaneous umbilical blood sampling   640.00 - 676-94 = O20.0 - O92.70
     (PUBS): 59012                           V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

     Fetal transfusion: 36460                640.00 - 676-94 = O20.0 - O92.70
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

     External cephalic version: 59412        640.00 - 676-94 = O20.0 - O92.70
                                             V23 - V23.9 = O09.0 - O09.93, V28.2 =
                                             Z36, V28.4 = Z36

18
Reproductive genetic counseling                                Postpartum visit
For a list of our contracted genetic counseling providers,     ACOG recommends that women visit their obstetric care
including our telephonic provider, InformedDNA, see our        provider approximately four to six weeks after delivery.2
online provider directory. Just go to the “Health Care         The visit should include:
Professionals” section at aetna.com. Then click
                                                               • An interval history and physical exam to evaluate the
“Online Provider Directory.”
                                                                 patient’s current status as well as her adaptation to
                                                                 the newborn
Rh immune globulin policy
                                                               • Specific questions including those related to
Antenatal Rh immune globulin is available to Rh negative         postpartum depression about breastfeeding
members by having blood drawn:                                 • An evaluation of weight, blood pressure, breasts
• In the PCP’s office and sent to a participating                and abdomen
  contracted or capitated laboratory. The obstetric            • A pelvic examination and Pap smear, if appropriate
  care provider may then provide and administer Rh             • Conception counseling and management
  immune globulin either before or after the results of
                                                               Payment for the postpartum visit is included in the
  the lab test come back, as determined by the physician.
                                                               global obstetric reimbursement fee.
• In the obstetric care provider’s office and sent
  to a participating contracted or capitated laboratory.
                                                               Non-emergency, non-obstetric
  The RhoGAM can be obtained through our
                                                               medical care
  specialty pharmacy network. Just visit
  aetnaspecialtypharmacy.com. The Rh immune                    If a member has a non-emergency, non-obstetric
  globulin can be administered by the                          medical need (for example, rashes, pneumonia, etc.),
  obstetric care provider or PCP.                              she should be directed either to her PCP (in plans
• At the hospital laboratory. The Rh immune globulin           that require the member to select a PCP) or to the
  may be administered in the outpatient department             appropriate participating physician (in other plans)
  of the hospital. No referral is needed for either the        for care and management.
  lab work or the Rh immune globulin administration            These services aren’t reimbursed on a fee-for-service
  at the hospital.                                             basis to the member’s obstetric care provider. Rather,
                                                               the obstetric care provider should notify the PCP or
Flu vaccination
                                                               appropriate participating physician of the member’s
The CDC recommends that healthy pregnant women                 medical problem and discuss any obstetric implications
who are in their second or third trimester during the flu      involved with the treatment of this problem. The PCP/
season get the flu vaccine. Also, women at any stage of        physician will then determine if any further referrals to
pregnancy with certain chronic medical conditions, such        specialists are necessary.
as asthma, diabetes mellitus or heart disease, should get
                                                               In some areas, the obstetric care provider may function
the vaccination.
                                                               as the member’s PCP and may refer the member to any
This vaccine is covered when administered to a                 participating provider for any covered, medically
pregnant woman. Physicians are reimbursed                      necessary services. To find out the details in your
separately for this immunization. For more information,        specific area, call us at 1-800-624-0756.
visit cdc.gov.

2
    American College of Obstetricians and Gynecologists, Committee Opinion No. 666.
    Optimizing Postpartum Care. June 2016.                                                                                 19
Spontaneous abortions                                          - 59514: cesarean delivery only
                                                                    - 59515: cesarean delivery and postpartum care
     An Ob/Gyn who provides care for a member with an
     incomplete, missed or completed spontaneous abortion           - 59614: vaginal birth after cesarean delivery and
     (CPT codes 59812, 59820, 59821 and 59830) may be                 postpartum care
     reimbursed for the office visit, as well as for related        - 59612: vaginal birth after cesarean delivery only
     procedures, regardless of whether the member is
     formally enrolled for obstetric care with the provider.       High-risk pregnancy management
     This acute care isn’t included in the global obstetric fee.   enhancement
     If a pregnancy results in a spontaneous abortion, the         We pay an additional fee to the obstetric care provider
     surgical procedure, necessary ultrasounds and prenatal        for managing a high-risk pregnancy. This applies to all
     care are paid at the Aetna Market Fee Schedule rate —         products when the following are true:
     regardless of whether or not there is a referral on file.
                                                                   • The member is enrolled in the Beginning Right
     All non-elective abortions are covered unless specifically
                                                                     maternity program, if available.
     excluded under the member’s plan.
                                                                   • Risk factors are identified.
     You should use office visit E&M codes when billing for        • There’s an increase in the intensity and/or frequency
     these services, as well as the ICD code indicating a            of care throughout the pregnancy.
     spontaneous abortion. Any ultrasounds done during the
                                                                   • Modifier 22 is added to the global obstetric fee claim.
     pregnancy that otherwise would have been included in
     the global obstetric fee should be billed with the ICD        When the obstetric care provider’s bill is submitted for
     code indicating a spontaneous abortion.                       global maternity care reimbursement, the request for
                                                                   enhanced reimbursement must include clinical
     The global fee for maternity care doesn’t apply when
                                                                   documentation of the additional care provided during
     there’s a pregnancy loss before 20 weeks. If a member
                                                                   the pregnancy. This should include the obstetric care
     is enrolled as an obstetric patient in the obstetric
                                                                   provider’s clinical summary and prenatal flow sheet,
     care provider’s practice and loses her pregnancy
                                                                   as appropriate.
     spontaneously, she is responsible for only the single
     copayment to her obstetric care provider paid at the          Examples of diagnoses that qualify for the high-risk
     first obstetric visit. Although we adjust payment to a        enhancement include but aren’t limited to:
     per-date-of-service payment of Aetna Market Fee
                                                                   • Insulin-dependent diabetes
     Schedule rates, only a single member copayment
     is applied.                                                   • Chronic hypertension on anti-hypertensive medication
                                                                   • Premature labor, managed throughout pregnancy
     Instructions for billing portions of prenatal                 • Chronic medical conditions that require weekly
     care and delivery                                               evaluation for uteroplacental insufficiency

     Physicians who provide total prenatal care and delivery       • Obstetric or medical conditions requiring prolonged or
     should bill CPT code 59400 for a vaginal delivery, 59514        repeated hospitalizations
     for a cesarean delivery, and 59610 for a vaginal birth
                                                                   Cell-free fetal nucleic acid screening
     after cesarean delivery. Physicians who provide some
     but not all of the prenatal care and delivery should bill     We cover cell-free fetal nucleic acid screening for women
     for the portion of prenatal care according to the             at high risk for genetic chromosomal abnormalities in the
     following CPT instructions:                                   fetus. High-risk conditions include maternal age greater
                                                                   than 35 at delivery, prior pregnancy with a chromosomal
     • 59425: four to six prenatal visits
                                                                   abnormality, abnormal fetal ultrasound or laboratory
     • 59426: seven or more visits                                 screening tests suggesting a chromosomal abnormality.
     • Use standard E&M codes for fewer than four                  (See Clinical Policy Bulletin #0464.)
       prenatal visits
      - 59409: vaginal delivery only
      - 59410: vaginal delivery and postpartum care

20
First and second trimester non-invasive                     Credentialing requirements for fetal
screening to provide individual risk                        aneuploidy screening involving nuchal
assessment for fetal aneuploidy                             translucency (NT) measurement
The following screenings for fetal aneuploidy are           To help ensure the accuracy of the NT screening, the
covered medical services for all pregnant women.            ultrasonographer performing the NT measurement and
(See Clinical Policy Bulletin #0282.)                       the sonologist interpreting the NT measurement must
• First trimester nuchal translucency (NT) measurement      be credentialed. The credentialing process in the United
  results combined with the results of first trimester      States is the Nuchal Translucency Quality Review (NTQR)
  serum analyte tests that include pregnancy-associated     program. Numerous professional societies have
  plasma protein A (PAPP-A) plus beta-human chorionic       promoted NT credentialing, including ACOG, the Society
  gonadotropin (hCG) or                                     for Maternal-Fetal Medicine and the March of Dimes.
• Integrated, sequential or contingent screening: first     Note that a large number of genetics laboratories,
  trimester results (NT, PAPP-A and hCG) plus second        including two Aetna-participating laboratories,
  trimester quad (maternal serum alpha-fetoprotein          Genzyme Genetics and Quest Diagnostics, require
  [MSAFP], unconjugated estriol, inhibin A and hCG)         evidence of credentialing of NT measurements to
  screening or                                              combine NT measurement and serum analyte values
• First trimester NT testing alone (without serum analyte   and report results for Aetna members. You can find
  screening) for multiple gestations or                     more information about the NTQR process and online
• Serum-integrated screening for pregnancies where          registration at ntqr.org.
  NT measurement isn’t available or can’t be obtained:      You can also see our Clinical Policy Bulletins
  first trimester (PAPP-A plus hCG) plus second trimester   on our secure provider website at
  quad (MSAFP, unconjugated estriol, inhibin A and hCG)     https://navinet.navimedix.com.
  screening or
• Second trimester serum analyte screening (see Clinical
  Policy Bulletin #0464)
Preauthorization isn’t required for NT testing or the
laboratory studies.

                                                                                                                       21
Other services covered for individual risk                       Intramuscular progesterone therapy is not an
     assessment for fetal aneuploidy                                  appropriate treatment for:

     • Amniocentesis or CVS regardless of maternal age                • Previous preterm birth due to a medical complication
       (see Clinical Policy Bulletin #0358)                             or “indicated preterm delivery” (for example, PIH,
     • Quad screening (maternal age plus alpha fetoprotein,             diabetes, placenta previa)
       estriol, total beta-hCG and dimeric inhibin A) in the          • Gestational age at initiation of therapy is greater
       second trimester for women of any age who don’t                  than 23 weeks’ gestation
       undergo first trimester testing (see Clinical Policy           • Member is in active preterm labor and 17P is being
       Bulletin #0464)                                                  used as a tocolytic
     You can access our Clinical Policy Bulletins                     • Member is pregnant with twins
     at aetna.com. Or find them on our                                • Member with cerclage in place
     secure provider website at
     https://navinet.navimedix.com.                                   Process to get intramuscular progesterone
                                                                      The drug 17P is a compounded drug and available only
     Screening schemes that aren’t covered include:
                                                                      through specialty pharmacies.
     • First trimester serum testing without NT testing
     • NT testing without serum testing                               Optional covered services to support members
                                                                      requiring 17P
     • Cell-free DNA testing in women at low risk of
       fetal aneuploidy                                               • Perinatology consult
                                                                      • Home nurse visit for instruction in self-administration
     Intramuscular progesterone therapy                                 of an intramuscular injection
     Pregnant women who experienced a previous                        • Preterm labor education program
     spontaneous preterm birth may be appropriate for
     intramuscular progesterone therapy (17 alpha­
                                                                      Home births
     hydroxyprogesterone caproate, or 17P) in subsequent              We consider planned deliveries at home and associated
     pregnancies. Weekly intramuscular administration of              services not medically appropriate. (See Clinical Policy
     250 mg of 17P from 15 through 20 completed weeks’                Bulletin #0329.)
     gestation and continued through 36 completed weeks of
     pregnancy has been shown to decrease the recurrent               Note: Provision of home births will be considered if
     spontaneous preterm birth rate by up to 33 percent.3             mandated by state law.

     Criteria for intramuscular progesterone therapy
     • Previous spontaneous preterm birth at less than
       37 weeks, including premature rupture of the
       membranes, or “PROM”
     • Gestational age at initiation of therapy is less than 23
       weeks’ completed gestation
     • Currently pregnant with a singleton pregnancy

     3
         American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 130.
         Prediction and Prevention of Preterm Birth. October 2012 (reaffirmed 2016).
22
Frequently asked questions

1. Can I be reimbursed for gynecological                    8. How can an Aetna member access her
   ultrasounds performed during a routine                      infertility benefits?
   gynecological visit without obtaining a referral?
                                                              Most Aetna plans require precertification for infertility
  Yes. Gynecological ultrasounds (CPT codes 76830,            treatment level care. Once you have a plan for
  76831, 76856 and 76857) are paid fee-for-service.           infertility treatment using injectable medication,
                                                              artificial insemination or assisted reproductive
2. Does Aetna cover the HPV vaccine?                          technology procedures, use our Infertility Program
                                                              Patient Registration Form to register with our
  Yes. We cover the HPV vaccine for covered female
                                                              National Infertility Unit. You’ll find the form at
  members from 9 to 26 years of age. (See Clinical Policy
                                                              aetnainfertilitycare.com.
  Bulletin #0726.)
                                                              Once you’ve completed the form, you or the member
3. Does Aetna have a support program for female               can fax it to us at 860-607-7476. We’ll review the form
   members diagnosed with breast cancer?                      and let the infertility specialist know if the member
                                                              meets the initial criteria to start using her infertility
  Our Breast Health Education Center is available for         treatment benefits. For more information, you or the
  members newly diagnosed with breast cancer who              member can call us at 1-800-575-5999. Except for
  are in an HMO, Aetna Health Network Only or Aetna           Thursdays, we’re here 8 a.m. to 5 p.m. ET (7 a.m. to
  Health Network Option plan.                                 3 p.m. PT), Monday through Friday. On Thursdays,
                                                              we close at 4 p.m. on the East Coast only.
4. Does Aetna cover BRCA genetic testing?

  Yes. We cover BRCA genetic testing for members who        9. Because Aetna no longer requires pregnancy
  meet one or more of the clinical criteria described in       precertification, is it necessary to notify you of
  Clinical Policy Bulletin #0227. To learn more about our      a member’s pregnancy?
  BRCA Genetic Testing program, call 1-877-794-8720.           No. But we do ask that you call the Beginning Right
                                                               maternity program at 1-800-272-3531 to begin the
5. How can I get approval for BRCA                             program enrollment process. The member must
   genetic testing?                                            complete the pregnancy risk survey to be considered
  To get a copy of our BRCA Precertification Information       for the program. We encourage you to inform the
  Request Form, go to aetna.com.                               member that she must call the Beginning Right
                                                               maternity program at 1-800-272-3531 or log in to
  You can also call us at 1-800-624-0756 for                   her member website at aetna.com to complete the
  more details.                                                program enrollment process.

6. Does Aetna cover genetic counseling?                        Enrollment in the program provides all eligible
                                                               members with:
  Yes. We cover genetic counseling for members with
  medical indications that support it. Face-to-face or         • Educational mailings
  phone counseling is available. See our online provider       • Our pregnancy risk survey
  directory at docfind.com for locations.                      • Nurse case management for members with
                                                                 selected medical problems who are classified as
7. How can I find out what infertility benefits an               high risk
   Aetna member has?                                           • Free gift when member enrolls by completing the
  Call the number listed on the member’s ID card.                pregnancy risk survey by 16 weeks of pregnancy
  We can also tell you if the member has a specific
  provider network.
                                                                                                                          23
10. How will I be reimbursed if an Aetna member          12. Will I be reimbursed for prenatal lab work
         miscarries after the first prenatal visit?               performed in the office?

        To be reimbursed for the visit and for any               Yes. Lab studies (CPT codes 85013, 85018, 82947,
        ultrasounds performed, submit the appropriate E&M        82948 and 82962) performed in the obstetric office
        and ultrasound codes with the diagnosis indicating       setting on pregnant members will be reimbursed
        spontaneous abortion (ICD10 - O03.9).                    outside of the global obstetric fee when billed with
                                                                 diagnosis codes V22-V22.2 = Z34.00 -Z33.1,
     11. Will I be reimbursed, in addition to the global         V27-V39.2 = Z37.0-Z38.1 and 640 - 677 =
         obstetric fee, when I visit an Aetna member             O20.0 - O94.
         during an antepartum inpatient stay?                    For other lab work, use our in-network labs.
        Yes. You’ll be reimbursed fee-for-service for each       You’ll find these providers in our online directory
        visit (CPT codes 99217 through 99239) you make to a      at aetna.com. Or refer to this list:
        member during an antepartum inpatient stay when          aetna.com/docfind/cms/assets/pdf/
        billed with diagnosis codes V22-V22.2 = Z34.00           DocFind_PDF_Lab_List9_10.pdf.
        -Z33.1, V27-V39.2 = Z37.0-Z38.1 and 640 - 677 =
        O20.0 - O94.

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