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Fillable Printable Form 411

Fillable Printable Form 411

Form 411

Form 411

CHAPTER 400
MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH
POLICY 411
WOMENS PREVENTATIVE CARE SERVICES
ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM411-1
AHCCCSMEDICAL POLICY MANUAL
411WOMENS PREVENTATIVE CARE SERVICES
INITIAL
EFFECTIVE DATE: 10/01/2015
Description
An annual well-woman preventative care visit is a covered benefit for women to obtain the
recommended preventive services, including preconception counseling.
Amount, Duration and Scope
A well-woman preventative care visit is covered on an annual basis when clinically
indicated.
A.WELL-WOMAN PREVENTATIVE CARE SERVICES DEFINITIONS
1.Human Papillovirus (HPV)- A sexually transmitted infection for which a series
of immunizations are available for both males and females beginning at a
recommen ded age o f 11 years up to 26 years of age. Refer to AMPM Policy 310-
M, Immunizations for further information related to immunization coverage.
2.Family Planning Counseling- The provision of accurate information and
discussion with a health care provider to allow members to make informed
decisions about the specific famil y planning methods available that ali gn with the
member’s lifestyle.
3.Mammogram - An x-ray of the breast used to look for early signs of breast cancer.
Coverage does not include genetic testing.
4.Clinical Breast Exam- A physical examination of the breasts by a health care
provider used as a primary diagnostic procedure for early detection of breast
cancer.
5.Preconception CounselingCounseling aimed at identifying/reducing behavioral
and social risks, through preventive and management interventions, in women of
reproductive age who are capable of becoming pregnant, regardless of whether
she is planning to conceive. This counseling focuses on the early detection and
management of risk factors beforepregnancy and includes efforts to influence
behaviors that can affect a fetus prior to conception The purpose of
preconception counseling is to ensure that a woman is healthy prior to pregnancy.
NOTE:Preconception counseling is considered included in the well-woman
preventative care visit and does not include genetic testing.
CHAPTER 400
MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH
POLICY 411
WOMENS PREVENTATIVE CARE SERVICES
ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM411-2
AHCCCSMEDICAL POLICY MANUAL
6.Well Exam- A physical examination in the absence of any known disease,
symptom, or specific medical complaint by the memberprecipitating the
examination.
B.CONTRACTOR REQUIREMENTS FOR WELL-WOMANPREVENTATIVECARE
SERVICES
Contractors must develop policies and procedures to monitor, evaluate, and improve
women’s participation in preventative care services.
Contractors must:
1.Inform all participating Primary Care Providers (PCPs) and Obstetrician/
Gynecologist (OB/GYN) providers of the availability of women’s preventative
care services, detailing the covered services included as part of the well-woman
preventative care visit, as outlined in Section C-1 of this policy.
2.Develop and implement a process for monitoring compliance with well-woman
preventative care services provider requirements.
3.Develop, implement, and maintain a process to inform members about women’s
preventative health services annually and within 30 days of enrollment with the
Contractor for newly enrolled members. This informationmust be provided in a
second language, in addition to English, in accordance with the requirements of
the AHCCCS Division of Health Care Management (DHCM) “Cultural
Competency” policy available in the AHCCCS Contractor Operations Manual
(available online at //www.azahcccs.gov/shared/ACOM/default.aspx).
a.This information must include:
i.The benefits of preventive health care,
ii.A complete description of the services available as described in this
section,
iii.Information on how to obtain these services. This must include a statement
that assistance with medically necessary transportation and scheduling
appointments is available to obtain well-woman preventative care
services, and
iv.A statement that there is no copayment or other charge for women’s
preventative care visit.
C.WELL-WOMAN PREVENTATIVE CARE SERVICES PROVIDER REQUIREMENTS
Provider requirements for well-woman preventative care services include the
following:
1.Covered Services Included as Part of a Well-Woman Preventative Care VisitAn
annual wel l -woman preventative care visit is intended for the identification of risk
factors for disease, identification of existing medical/mental health problems, and
CHAPTER 400
MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH
POLICY 411
WOMENS PREVENTATIVE CARE SERVICES
ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM411-3
AHCCCSMEDICAL POLICY MANUAL
promotion of healthy lifestyle habits essential to reducing or preventing risk
factors for various disease processes. As such, the well-woman preventative care
visit is inclusive of a minimum of the following:
a.A physical exam (well exam) thatassesses overall health.
b.Clinical breast exam.
c.Pelvic exam (as necessary, according to current recommendations and best
standards of practice).
d.Review and administration of immunizations, screenings and testing as
appropriate for age and risk factors. Refer to AMPM 310-H, HealthRisk
Assessment and Screening Testsfor further information pertaining to health
risk assessments and associated screening tests.
NOTE:Genetic screening and testing is not covered, except as described in
AMPM Chapter 300, Medical Policy for Covered Services.
e.Screening and counseling is included as part of the well-woman preventive
care visit and is focused on maintaining a healthy lifestyle and minimizing
health risks, that addresses at a minimum the following:
i.Proper nutrition
ii.Physical activity
iii.Elevated BMI indicative of obesity
iv.Tobacco/substance use, abuse, and/or dependency
v.Depression screening
vi.Interpersonal and domestic violence screening, that includes counseling
involving elicitation of information from women and adolescents about
current/past violence and abuse, in a culturally sensitive and supportive
manner to address current health concerns about safety and other current
or future health problems
vii.Sexually transmitted infections
viii.Human Immunodeficiency Virus (HIV)
ix.Family planning counseling
x.Preconception counseling that includes discussion regarding a healthy
lifestyle before and between pregnancies that includes:
(a)Reproductive history and sexual practices
(b)Healthy weight, including diet and nutrition, as well as the use of
nutritional supplements and folic acid intake
(c)Physical activity or exercise
(d)Oral health care
(e)Chronic disease management
(f)Emotional wellness
(g)Tobacco and substance use (caffeine, alcohol, marijuana and other
drugs), including prescription drug use
(h)Recommended intervals betweenpregnancies
NOTE:Preconception counseling does not include genetic testing.
CHAPTER 400
MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH
POLICY 411
WOMENS PREVENTATIVE CARE SERVICES
ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM411-4
AHCCCSMEDICAL POLICY MANUAL
f.Initiationof necessary referrals when the need for further evaluation,
diagnosis, and/or treatment is identified.
2.Well-Woman Preventative Care Service Standards
Immunizations- AHCCCS will cover the Human Papilloma Virus (HPV)
vaccine for female members 11 to 26 years of age. For adult immunizations, refer
to Policy 310-M, Immunizations. Providers must coordinate with The Arizona
Departmen t of H ealth Se rvices (ADHS) V accines fo r Children (VFC) Pro gram in
the delivery of immunization services if providing vaccinations to Early and
Periodic Screening, Diagnostic and Treatment (EPSDT) aged members less than
19 years of age. Immunizations must be provided according to the Advisory
Committee on Immunization Practices Recommended Schedule. (Refer to the
CDC website at //www.cdc.gov/vaccines/schedules/index.html where this
information is included). Providers must enroll and re-enroll annually with the
VFC program, in accordance with AHCCCS contract requirements in providing
immunizations for EPSDT aged members less than 19 years of age, and must
document each EPSDT age member’s immunizations in the Arizona State
Immunization Information System (ASIIS) registry. In addition, the Contractor
shall not utilize AHCCCS funding to purchase va ccines covered through the VFC
program for members younger than 19 years of age.
Screenings- Refer to AMPM Policy 310-H, Health Risk Assessment and
Screening Testsfor further details pertaining to specific screening and limitations
related to health risk assessments and associated screening tests for those
members over 21 years of age. Refer to AMPM Policy 430, EPSDT Servicesfor
further details related to covered services for members less than 21 years of age.
D.ADDITIONAL COVERED RELATED SERVICES
Refer to AMPM Policy 310-H, Health Risk Assessment and Screening Testsfor further
details pertaining to specific screening and limitations related to health risk assessments
and associated screening tests.
Refer to AMPM Policy 420, Family Planningfor further details related to the family
planning covered services.
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