Perinatal Care Prior Authorization Form

Prior Authorization For Perinatal Care

For Services at: UnityPoint Health - Meriter Center for Perinatal Care
What type of prior authorization is being requested?

Routine: Applies to routine service requests. These should be submitted at least 15 days ahead of scheduled service. This applies to most requests. Request must be approved before service can be performed.Administratively Urgent: Routine service scheduled prior to the 15 days allowed to review, reserved for filling cancellationsUrgent: There is imminent risk to the member’s health if service is not received within 72 hours. This box should not be used for scheduling conveniences.
**GHC-SCW Care Management reserves the right to change referral type should the request not match definitions listed above.**
Patient Information
Patient's Member Number:*
Patient's Name: *
Full Name
Patient's Date of Birth *

MonthDayYear
Date
Patient's Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Referred by Provider
Referring Provider's Name *
Full Name
Referring Provider's Email Address*
example@example.com
Referring Provider's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Referring Provider's NPI #:*
Prior Authorization Form Submitted By:*
Full Name
Referring Provider Phone #:*
Please enter a valid phone number.
Referring Provider Fax #:
Please enter a valid fax number.
REFERRED TO FACILITY/PROVIDER
Facility Name: UnityPoint Health - Meriter Center for Perinatal Care [26628]

Facility Address: 202 S. Park St.

City/State/Zip: Madison, WI 53715

Facility NPI ID#: N/A

Facility Phone #: (608) 417-6667

Facility Fax #: (608) 417-6364

Facility Tax ID #: 390806367
Please click "Yes" to confirm this prior authorization form is for services at UnityPoint Health - Meriter Center for Perinatal Care (facility information above).

Yes
Services Requested and Diagnosis Information

Supporting clinical documentation must accompany this request.
What services are being requested for this prior authorization?*

Pre-Pregnancy Consult (One Visit)Prenatal ConsultationPerinatal Consult + Transfer of CarePerinatal Consult + Shared CareFetal Echocardiogram [76826]Targeted Ultrasound [76811]AmniocentesisCVSCertified Diabetes EducatorOther
Diagnosis Information *

Diagnosis Code

Diagnosis Description

Procedure CodeState / Province

Procedure Description
Please upload all supporting clinical documentation to accompany this request:

Cancelof
Number Of Visits:*
Frequency of Visits:*
Date(s) Of Service:*
Month/Day/Year
Comments:*
A referral is not a guarantee of eligibility or benefits under the member’s health plan. Payment will be made in accordance with the member’s plan benefits at the time the service is rendered. Please call Member Services at (800) 605-4327 if you have questions about benefits. Retrospective requests will not be accepted.

Prior Authorization and Clinical Information Fax Number: (608) 831-6099
Where should GHC-SCW members go for scans/services?

Questions? Please call GHC Care Management at (608)831-6099

Service	Location
Amniotic Fluid Index (AFI)	GHC-SCW Medical Imaging
20-week Anomaly Scan/Anatomy Scan (Level I Ultrasound)	GHC-SCW Medical Imaging EXCEPT for patients with a pre-pregnancy BMI ≥ 30 risk or factors in List 1 below.
Targeted Ultrasound*	UnityPoint Health - Meriter Center for Perinatal Care *See List 1 below for covered indications
Growth Scan / Follow- Up Scan	GHC-SCW Medical Imaging EXCEPT for patients who have transferred care to Maternal-Fetal Medicine, or patients who have abnormal ultrasound findings, then follow-up should be at UnityPoint Health - Meriter Center for Perinatal Care.
Biophysical Profile (BPP)	GHC-SCW Medical Imaging
Cervical Length	HC-SCW Medical Imaging EXCEPT for diagnoses of incompetent cervix or cerclage, which should be at UnityPoint Health - Meriter Center for Perinatal Care.
Dating Ultrasound	GHC-SCW Medical Imaging
Non-Stress Tests (NST)	Ok to take place at the office of the Primary OB provider
12- to 14-Week Ultrasound	GHC-SCW Medical Imaging (including dichorionic twin gestation). EXCEPT unknown chorionicity, monochorionic twin pregnancies, abnormal NIPS results, previous abnormal ultrasound findings in current pregnancy then should be at UnityPoint Health - Meriter Center for Perinatal Care. With full transfer of care to Maternal-Fetal Medicine, can be at GHC-SCW or Maternal-Fetal Medicine, per Maternal-Fetal Medicine provider recommendation.
NT ultrasound	NT ultrasound has been replaced by NIPS. NT ultrasound is not authorized. EXCEPT for situations of twin demise, repeated non-reportable NIPS testing, or visibly abnormal nuchal area; in those cases NT ultrasound as part of the first trimester screen should be done at UnityPoint Health - Meriter Center for Perinatal Care, with Meriter genetic counseling.
Genetic Counseling	GHC-SCW for prenatal genetic counseling (e.g. NIPS, abnormal quad, family history, carrier screen). Meriter genetic counselors when member has transferred care to MFM, with abnormal ultrasound findings, or in conjunction with CVS or amniocentesis. UW genetic counselors for general genetics or cancer indications.
NIPS/ NIPT	GHC-SCW labs
Carrier screening	GHC-SCW labs. No prior authorization is required for cystic fibrosis and spinal muscular carrier screening done at GHC-SCW labs, fax order to GHC labs. For other carrier screening refer patient to GHC-SCW genetic counselor for coordination.
Genetic Testing on Fetus	UnityPoint Health - Meriter Center for Perinatal Care for CVS and amniocentesis. Prior authorization is not needed for CVS or amnio samples for karyotype, microarray, FISH prenatal panel or cystic fibrosis mutation panel in cases of echogenic bowel. Prior authorization is needed for any other genetic testing from fetal samples. Parental blood samples can be collected same day as procedure at Meriter to accompany fetal samples as needed.
Non-Genetic Lab Tests	If patient has GHC-SCW Primary Care Provider (PCP): labs at GHC-SCW. If patient has UW-Health or UnityPoint Health - Meriter PCP: labs can be at the PCP office, OB office or at GHC-SCW labs. For full transfer of care to MFM: routine labs (not genetic testing) can be done at MFM. If a lab is needed for same day care (e.g. antibody screen for a procedure happening that day): labs can be done at the specialist’s office that day, regardless of PCP.
Diabetes Management	UnityPoint Health - Meriter Center for Perinatal Care for pregnant patients with type 1 diabetes, pre-existing type 2 diabetes, gestational diabetes requiring insulin, pre-preconception consult for type 1 or type 2 diabetes. For pre-diabetes and gestational diabetes not requiring insulin, GHC-SCW if OB provider is a GHC-SCW Provider and UnityPoint Health - Meriter Center for Perinatal Care if OB Provider is a non-GHC-SCW Provider.

Table 2: Indications for a Targeted Ultrasound at Perinatal Center

Questions? Please call GHC Care Management at (608)831-6099

List 1: Indications for a Targeted Ultrasound at Perinatal Center

Previous fetus or child with a congenital, genetic, or chromosomal abnormality, with potential for prenatal ultrasound findings
Known or suspected fetal anomaly or known or suspected fetal growth restriction in the current pregnancy
Fetus at increased risk for a congenital anomaly, genetic, or chromosomal condition, such as the following:
a. Maternal pregestational diabetes or gestational diabetes diagnosed before 24 weeks’ gestation
b. Pregnancy conceived via in vitro fertilization (IVF)
c. Pre-pregnancy maternal body mass index of 30 kg/m2 or higher
d. Multiple gestations
e. Abnormal maternal serum analytes, abnormal or indeterminate NIPS/cell free DNA results
f. Teratogen exposure
g. First-trimester cystic hygroma or nuchal translucency measurement of 3.0 mm or greater
h. Parental carrier of a chromosomal or genetic abnormality with potential for prenatal ultrasound findings
i. Maternal age of 35 years or older at delivery without normal NIPS results (Note that if a patient has normal NIPS, GHC-SCW does not consider targeted ultrasound medically necessary for the indication of advanced maternal age)
j. Positive screening test results for aneuploidy
k. Aneuploidy marker noted on an ultrasound examination (excluding isolated finding of choroid plexus cyst, intracardiac echogenic focus or pyelectasis)
l. First-trimester cystic hygroma or nuchal translucency measurement of 3.0 mm or greater
m. Family history of 1st or 2nd degree relative to the fetus of congenital anomaly when both an increased risk to the fetus and potential for prenatal ultrasound detection are present (e.g. open neural tube defect, cleft lip/palate, congenital heart defect)
Other conditions affecting the fetus, including the following:
a. Congenital infections with known teratogenic effects
b. Maternal drug use
c. Alloimmunization
d. Oligohydramnios / Polyhydramnios
Suspected placenta accreta spectrum (PAS) or risk factors for PAS such as placenta previa in the third trimester or placenta overlying a prior cesarean scar site

Should be Empty:

Prior Authorization For Perinatal Care

Patient Information

Referred by Provider

REFERRED TO FACILITY/PROVIDER

Services Requested and Diagnosis Information

Where should GHC-SCW members go for scans/services?

Table 2: Indications for a Targeted Ultrasound at Perinatal Center

List 1: Indications for a Targeted Ultrasound at Perinatal Center