Obstetric Services: Global-Fee Method of Payment

(A) Definitions (1) Coverage Provider. a physician, certified nurse midwife, physician assistant, or certified nurse practitioner that is either a member of the same group practice as the Primary Provider, or who is in a separate practice from the Primary Provider and has a back-up coverage arrangement with the Primary Provider. (2) Global Fee. a single inclusive fee for all prenatal and postpartum visits, and the delivery. The global fee is available only when the conditions in 130 CMR 433.421 are met. (3) Non-coverage Provider. any provider that has no employment, contractual, or practice-coverage relationship with the Primary Provider, or his or her practice. (4) Primary Provider. a physician or certified nurse midwife who has assumed responsibility for performing or coordinating a minimum of six prenatal visits, the delivery, and a minimum of one postpartum visit for a member. (B) Conditions for Global Fee. (1) Primary Provider Responsibilities. In order to qualify for payment of the global fee, the primary provider must perform, or coordinate a coverage provider’s performance of, a minimum of six prenatal visits, the delivery, and a minimum of one postpartum visit for the member, and must also satisfy all other requirements in 130 CMR 433.421. The primary provider is the only clinician that may claim payment of the global fee. As an exception to 130 CMR 450.301(A): Claims and 130 CMR 433.451(A), the primary provider is not required to perform all components of the obstetric global service directly. All global-fee claims must use the delivery date as the date of service. (2) Standards of Practice. All of the components of the obstetric global service must be provided at a level of quality consistent with the standards of practice of the American College of Obstetrics and Gynecology. (3) Coordinated Medical Management. The primary provider or coverage provider must coordinate the medical and support services necessary for a healthy pregnancy and delivery. This includes the following: 4. Program Regulations (a) tracking and follow-up of the patient's activity to ensure completion of the patient care plan, with the appropriate number of visits; (b) coordination of medical management with necessary referral to other medical specialties and dental services; and (c) referral to WIC (the Special Supplemental Food Program for Women, Infants, and Children), counseling, and social work as needed. (4) Health-Care Counseling. In conjunction with providing prenatal care, the primary provider or coverage provider must provide health-care counseling to the woman over the course of the pregnancy. Topics covered must include, but are not limited to, the following: (a) EPSDT screening for teenage pregnant individuals; (b) smoking and substance abuse; (c) hygiene and nutrition during pregnancy; (d) care of breasts and plans for infant feeding; (e) obstetrical anesthesia and analgesia; (f) the physiology of labor and the delivery process, including detection of signs of early labor; (g) plans for transportation to the hospital; (h) plans for assistance in the home during the postpartum period; (i) plans for pediatric care for the infant; and (j) family planning. (5) Obstetrical-Risk Assessment and Monitoring. The primary provider or coverage provider must manage the member's obstetrical-risk assessment and monitoring. Medical management requires monitoring the woman's care and coordinating diagnostic evaluations and services as appropriate. The professional and technical components of these services are paid separately from the global fee and should be billed for by the servicing provider on a fee-for-service basis. Such services may include, but are not limited to, the following: (a) counseling specific to high-risk patients (for example, antepartum genetic counseling); (b) evaluation and testing (for example, amniocentesis); and (c) specialized care (for example, treatment of premature labor). (C) Multiple Providers. When more than one provider is involved in prenatal, delivery, and postpartum services for the same member, the following conditions apply. (1) The global fee may be claimed only by the primary provider and only if the required services (minimum of six prenatal visits, a delivery, and a minimum of one postpartum visit) are provided directly by the primary provider, or a coverage provider. (This constitutes an exception to 130 CMR 450.301(A): Claims and 130 CMR 433.451(A).) (2) If the primary provider bills for the global fee, no coverage provider may claim payment from the MassHealth agency. Payment of the global fee constitutes payment in full both to the primary provider and to all coverage providers who provided components of the obstetric global service . (3) If the primary provider bills for the global fee, any non-coverage provider who performed prenatal visits or postpartum visits for the member may claim payment for such services only on a fee-for-service basis. If the primary provider bills for the global fee, no non-coverage provider may claim payment for the delivery. (4) If the primary provider bills on a fee-for-service basis and does not bill a global fee, any other coverage or non-coverage provider may claim payment on a fee-for-service basis for prenatal, delivery, and postpartum services they provided to the same member. 4. Program Regulations (D) Recordkeeping for Global Fee. The primary provider is responsible for documenting, in accordance with 130 CMR 433.409, all the service components of a global fee. This includes services performed by the primary provider and any coverage providers. All hospital and ambulatory services, including risk assessment and medical visits, must be clearly documented in each member's record in a way that allows for easy review of her obstetrical history. (130 CMR 433.422 and 433.423 Reserved) 4 Program Regulations