Medicaid Obstetrical and Maternal Services (MOMS) Billing Guidelines

Developed by Computer Sciences Corporation (CSC), 2005

Questions Frequently Asked About MOMS

1. What is the purpose of the MOMS program?

The purpose of the MOMS program is to improve access to maternity care services by providing increased Medicaid fees to private practicing physicians, nurse practitioners and licensed midwives. A key component of the MOMS program is the requirement that Health Supportive Services (HSS) be available to Medicaid-eligible pregnant women.

2. What are HSS?

HSS include the following:

  • Outreach
  • Presumptive eligibility and assistance with the Medicaid application process
  • Health education
  • Psychosocial assessment and counseling
  • Nutrition assessment and counseling
  • Case management, including referrals to WIC, substance abuse treatment programs, and other community resources
  • Follow-up on missed appointments
  • Arrangement of transportation for prenatal care
  • HIV counseling and testing services
  • Non-medical postpartum services

    • 3. Which patients should be referred for HSS?

    Due to recent eligibility expansions, more women are now eligible for Medicaid.

    All Medicaid-eligible (or potentially eligible) pregnant women should be referred for HSS to determine eligibility, to get assistance with the Medicaid application and to receive services as outlined in #2 above.

    This table lists eligibility levels for pregnant women and children:
    Medicaid (Annual and Monthly) Income Levels for Pregnant Women and Children

    4. Who provides HSS?

    Health Supportive Services can be rendered by approved Article 28 hospitals or diagnostic & treatment centers, Article 36 certified home health agencies, county health departments, physicians, licensed midwives, nurse practitioners.

    5. Where do I find an HSS provider?

    A list of eligible HSS providers is available from:

    Bureau of Women’s Health
    Prenatal Health Unit
    New York State Department of Health
    Empire State Plaza
    Corning Tower -Room 1882
    Albany, New York 12237

    qej03@health.state.ny.us

    (518) 474-1911

    or

    Find a MOMS HSSP near you.

    6. Is there any MOMS information available on the internet?

    Yes. Medicaid Obstetrical and Maternal Services (MOMS)

    7. What are my obligations?

    As a MOMS provider, you agree to inform all Medicaid-eligible (or potentially eligible) women about the presence, location, coverage, and potential benefits of HSS, and to make a written referral, using a form provided by the State or an equivalent form. One copy will be given to the client, and one copy will be sent to the HSS provider.

    You also agree to the timely exchange of information with the HSS provider on an ongoing basis regarding:

  • The availability of your services
  • Referral and appointment information
  • Adoption of procedures for following up on missed appointments
  • Consulting on specific patient needs
  • Bringing forth problems for discussion and resolution
  • Mutually-agreed-upon data pertinent to patient assessment and patient services

    • Additionally, as a MOMS provider you agree to safeguard patient confidentiality and to obtain patient consent.

    8. When should I make the referral to the HSS?

    Written referrals must be made prior to, or immediately following, the first prenatal medical visit.

    9. If, after my referral, the patient refuses the services of the HSS provider can I still bill at the enhanced fee?

    Yes. You can bill the enhanced fee as long as the appropriate referral form has been completed, with one copy given to the client and one copy sent to the HSS provider.

    10. Is there a written agreement with the HSS provider?

    Yes. As a MOMS provider, you must sign an agreement that links you with an HSS provider. You must agree to participate and cooperate in programs and procedures for the provision of comprehensive prenatal services to New York State Medicaid-eligible women.

    11. Can I have a written agreement with more than one HSS provider?

    Yes. You may have signed agreements with multiple HSS providers. However, it is recommended that the number be limited to enhance better communication and consistency of service.

    12. If my written agreement is with a CHHA HSS which only provides services to one county and my patients live in multiple counties, must I establish an HSS agreement with an additional HSS provider?

    Yes. All Medicaid-eligible patients must have access to HSS.

    13. Can I arrange for HSS by telephone?

    Yes. However, any arrangements made by telephone must have written confirmation using the HSS referral form.

    14. If I am a full-time or part-time physician employed by a hospital or clinic, can I enroll in the MOMS program and be paid at the MOMS rates for services I render to patients registered at the hospital or clinic?

    No. If the physician is salaried by a freestanding clinic for patient care, he/she may not bill fee-for-service for care provided at any of that clinic’s sites.

    The costs used to develop the Medicaid payment to a hospital or clinic may include physician salaries for administration, teaching and/or patient care. Medicaid should not be billed on a fee-for-service basis for patient care which is covered by a facility’s rate, since this would be a duplicate billing.

    If a hospital includes the physician’s patient care salary in its Medicaid cost report that salary covers care of the facility’s patients in both the inpatient and outpatient setting. Medicaid should not be billed on a fee-for-service basis for hospital outpatient department patients, even when they are seen in the inpatient setting.

    15. I’m providing prenatal services to patients at a PCAP Clinic, (an approved DOH Article 28 facility). What services can I bill Medicaid at the MOMS rates?

    You can bill MMIS the MOMS rates for "delivery only" (codes 59409, 59612, 59514, or 59620). MOMS providers rendering services at an approved DOH Article 28 facility PCAP site will be reimbursed for prenatal and postpartum care by PCAP according to the terms of a pre-negotiated contract between the program (PCAP) and the provider.

    16. If I provide a consultation in my office to a patient registered with PCAP, for what services can I bill the MOMS rate?

    You cannot bill Medicaid (MMIS) for services provided to a patient registered with a PCAP. Except for visits to specialists (including perinatologists), all prenatal and postpartum care services provided to these patients will be reimbursed by the program (PCAP). If a PCAP patient is referred to a specialist, the specialist should bill Medicaid according to his/her usual practice (i.e., this would depend on whether the specialist is salaried by a facility or is in a private office setting).

    17. Are service authorizations necessary prior to billing MOMS services?

    No. Service authorizations are not required for prenatal or postpartum care for HSS visits for CHHAs, clinics enrolled with specialty code 904*, or physician services billed on paper with specialty code 159. These services are all exempt from Utilization Thresholds (UTs). However, other Medicaid services that are not pregnancy related may be subject to UT’s.

    *Providers billing electronically using HIPAA 837 Institutional (Article 28 clinics) or 837 Professional (physicians) must enter SA exception code 7 in loop 2300 Ref 02 to override the UT requirement. There is no field entry for specialty code within the HIPAA 837 formats.

    18. What procedure codes do I use for MOMS reimbursement?

    Procedure codes.

    19. What other billing requirements are associated with MOMS?

    Billing requirements and the use of certain procedure codes and specialty codes may vary for MOMS physicians and licensed midwives based on the existence of a contract. The following details the use of appropriate procedure codes, sample claim forms, and other pertinent billing information.

    • MOMS physicians and licensed midwives billing "delivery only" codes may bill hospital E/M codes for inpatient postpartum visits. However, specialty code 159* cannot be used in conjunction with E/M codes. Physicians enrolled with the Department of Health as specialists may use their assigned specialty code* when billing E/M codes.
    • MOMS physicians who are not PCAP subcontractors may bill at the enhanced MOMS rates for certain radiology codes (76801, 76802, 76805, 76810, 76811, 76812, 76815, 76816, 76817, 76818, 76819) on a fee-for-service basis. There is a professional/technical split for billing purposes, depending on the place of service.
      If the procedure was performed in the hospital and the physician interpreted the results of the test, the MOMS physician will bill for the procedure with modifier 26 and specialty code 159*.
      The referring physician’s Name and Medicaid ID# or License Number and License Type are required when billing for these radiology codes.
    • "Global" reimbursement includes all prenatal visits, delivery, and all postpartum visits.

    * The use of specialty codes are applicable to the proprietary electronic format and paper billing only.

    20. Can a MOMS physician bill Medicaid for interpretation (professional component) for fetal non-stress tests performed in the hospital or a D&T center?

    No. MOMS physicians who are not PCAP subcontractors can only bill the enhanced fee for fetal non-stress tests when they are performed in the provider’s office. The fetal non-stress test (procedure code 59025) cannot be split-billed into professional/technical components. If the procedure was performed in the hospital or D&T center and the MOMS physician interprets the results of the test, the physician should be reimbursed by the hospital or D&T center according to the terms of the contract or arrangement between the facility and the physician.

    21. Who can I call if I have further questions?

    Questions about billing procedures should be directed to:

    Computer Sciences Corporation
    Practitioner Services
    1-800-343-9000

    Questions about policy, related to the MOMS program, should be directed to:

    New York State Department of Health
    Office of Medicaid Management
    518-486-6562

    MOMS Program - Attachment
    Sample Claim Forms, Procedure Codes, and Fees

    Please note the following information regarding the sample claims in this attachment:

    • The following claim form examples are for illustrative purposes only. Detailed billing instructions are in the Billing section of the MMIS Provider Manual.
    • Physician’s claims for services not found on the list of MOMS enhanced fee procedures should not be billed with specialty code 159*.

    * The use of specialty codes are applicable to the proprietary electronic format and paper billing only.

    Sample claims are as follows: