New Requirements for Fee-For-Service Delivery Claims

Effective for dates of services on or after Feb. 1, 2018, fee-for-service delivery claims for recipients who reside in a county not served by an Alabama Medicaid (Medicaid) Maternity Care Program must contain the date of last menstrual period and the date of first prenatal visit. This information is not required for hospital claims.

Counties not included in a Medicaid Maternity Care Program:

District 10:  Autauga, Bullock, Butler, Crenshaw, Elmore, Lowndes, Montgomery and Pike
District 12: Baldwin, Clarke, Conecuh, Covington, Escambia, Monroe and Washington

Soft Denial:
Claims without the date of last menstrual period and the date of the first prenatal visit will receive a “soft” denial.  This means the claim will process, but the provider will receive an alert to remind them to include the information.

Hard Denial:
On Feb. 1, 2019, claims that do not include the date of last menstrual period and the date of the first prenatal visit will be denied.

Some examples of what a provider can expect to see on the denied claim include:
Edit 330 – DTP SEGMENT DATE IS INVALID
Edit 331 – DATE LAST MENSTRUAL PERIOD MISSING OR IN FUTURE
Edit 332 – DATE FIRST PRENATAL VISIT MISSING OR IN FUTURE

Claims with the procedure codes below must include the date of last menstrual period and date of the first prenatal visit:

• 59400-59410     Vaginal delivery
• 59510-59515      Cesarean delivery
• 59610-59622     Delivery after previous cesarean delivery

How can a fee for service provider submit a claim?

• For claims submitted through 5010 X12 837P:
  1. Enter the date of the patient’s last menstrual period in a DTP segment in loop 2300 with a qualifier of 484
  2. Enter the date of the patient’s first prenatal visit in a DTP segment in loop 2300 with a qualifier of 454

• For claims submitted on the Medicaid Interactive Web Portal:
  1. Enter the date of the patient’s last menstrual period in the field labeled “last menstrual period date”
  2. Enter the date of the patient’s first prenatal visit in the field labeled “first prenatal visit date”
• For paper claims submitted on a CMS form 1500:
  1. Enter the patients last menstrual period in block 14
  2. Enter QUAL the value “484” to identify the information in block 14 as the date of the last menstrual period.
  3. Enter QUAL the value “454,” which identifies the information entered as the date of the first prenatal visit in block 15
  4. Enter the date of the patient’s first prenatal visit in block 15
  5. If no prenatal care was received, the date entered in block should be the date of the first contact during the pregnancy.

*Reminder:  Medicaid requires all claims be filed electronically unless they are required to be submitted on paper.

• PES does not currently allow claims to be submitted with this information, but a software upgrade will be available prior to claims denying for not containing the information.

Note:
Providers within the Maternity Care Program must continue to follow guidelines outlined in the April 13, 2017 ALERT. Please visit http://medicaid.alabama.gov/alert_detail.aspx?ID=12209 for a copy of the ALERT.

Please direct questions to the Fiscal Agent, Provider Assistance Center at (800) 688-7989.