The Health Care Authority has revised both its inpatient hospital and physician-related services provider billing guides to reflect changes to its policy regarding payment for elective early deliveries. Effective January 1, 2016, HCA will not pay for professional or hospital charges related to elective early deliveries before 39 weeks gestation, unless the physician documents that the early delivery is medically necessary. HCA considers an early elective delivery to be medically necessary if the mother or fetus has a listed diagnosis in the Joint Commission’s current table of conditions, or otherwise, the physician documents a clinical condition that supports medical necessity. For cases that meet either criteria the hospital and physician needs to bill Expedited Prior Authorization (EPA) #870001375 for deliveries prior to 39 weeks and EPA #870001378 for elective deliveries of gestation greater than 39 weeks.
Additional information can be found on page 55 of the Inpatient Hospital Services Provider Guide and page 178 of the Physician-Related Services/Healthcare Professional Services Provider Guide. (Andrew Busz)