Effective Date: July 1, 2020

Purpose:
This policy provides reimbursement guidelines for centering group prenatal care for professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible (FIDE)-SNP

Definitions:

• CenteringPregnancy: A nationally recognized model of prenatal care provided in a group setting that gives members more time with their provider and also encourages interaction with other expecting mothers. CenteringPregnancy is also shown to improve a wide range of birth outcomes including lowering risk of preterm births by 33-47%, reducing low birth weights and increasing breastfeeding rates.

• CPT Code 99078: Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)

• Modifier -TH: Obstetrical treatment/services, prenatal or postpartum

Policy:
Horizon NJ Health shall reimburse for group prenatal care via CenteringPregnancy for eligible pregnant members. In order to be reimbursed, the site must be accredited by the Centering Healthcare Institute. Centering Healthcare Institute is a non-profit organization that works closely with healthcare providers from all sectors to transform healthcare delivery and outcomes.

The centering program consists of ten (10) prenatal sessions, each ninety (90) minutes to two (2) hours long. The education and discussion must include the centering curriculum materials and cover topics including but not limited to, nutrition, stress management, labor and delivery, breastfeeding and infant care. In order to be reimbursed, each session must be held as a group setting consisting of 2-20 pregnant women with similar due dates.

Horizon NJ Health will reimburse CenteringPregnancy sessions attended by the member up to ten (10) sessions per pregnancy. Each session must be billed with CPT code 99078, affixed with modifier –TH and have a pregnancy diagnosis. (ICD 10 series Z34 for normal pregnancy or series O09 for high risk pregnancy)

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon NJ Health shall reimburse CenteringPregnancy services when billed by an accredited site. Claims billed by a non-accredited site shall deny in full.

Horizon NJ Health shall reimburse claims only if billed with CPT code 99078, modifier -TH appended and an appropriate maternity diagnosis code. Claims billed without modifier -TH and/or without the appropriate maternity diagnosis code will deny in full.

Horizon NJ Health shall allow up to ten (10) sessions of CenteringPregnancy per pregnancy. Any session(s) billed over ten (10) per pregnancy shall deny in full.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

Resources:
New Jersey State Medicaid Contract, Section 4.2.3F “Women’s Health Services”

Centering Healthcare Institute
https://www.centeringhealthcare.org/

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.