Effective 4/1/2017, PEIA restricts any Cesarean Section, labor induction or any delivery following labor induction to the following criteria:
Gestational age of the fetus must be determined to be at least 39 weeks and fetal lung maturity must be established before delivery.
If the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery.
Any Cesarean section, labor induction, or delivery that follows labor induction and that occurs prior to 39 weeks of gestation will be denied if the procedure is not considered to be, and documented as, medically necessary or the result of spontaneous labor.
Physician claims for obstetric delivery will require one of the following modifiers:
UB-Medically necessary delivery prior to 39 weeks of gestation UC-Delivery at 39 weeks of gestation or later
UA-Non-medically necessary delivery prior to 39 weeks of gestation
Records will be subject to retrospective review. If a Cesarean section, labor induction, or delivery following labor induction fails to meet the criteria for medical necessity, payments made will be subject to recoupment.
Recoupment will apply to the physician charge for delivery.
f you have questions, you may call HealthSmart Benefit Solutions at 1-888-440-7342 or PEIA at 1-888-680-7342.
UniCare Health Plan Update
Unicare invites all providers to monthly provider orientation sessions.
Date: Third Tuesday of each month
ime: noon – 1:00 PM Event Number: 593 498 042
You will learn about:
Who UniCare is
Healthcare Management Services
Community Outreach Initiatives
Other Resources Available
If you have additional questions, contact UniCare at (888) 611-9958.