Or. Admin. Code § 410-130-0580 - Hysterectomies and Sterilization
(1)
Refer to OAR 410-130-0200 Prior
Authorization, Table 130-0200-1 and
410-130-0220 Not Covered/Bundled
Services, Table 130-0220-1.
(2)
Hysterectomies performed for the sole purpose of sterilization are not
covered.
(3) All hysterectomies,
except radical hysterectomies, require prior authorization (PA).
(4) A properly completed Hysterectomy Consent
form (DMAP 741) or a statement signed by the performing physician, depending
upon the following circumstances, is required for all hysterectomies:
(a) When a woman is capable of bearing
children:
(A) Prior to the surgery, the
person securing authorization to perform the hysterectomy must inform the woman
and her representative, if any, orally and in writing, that the hysterectomy
will render her permanently incapable of reproducing;
(B) The woman or her representative, if any,
must sign the consent form to acknowledge she received that
information.
(b) When a
woman is sterile prior to the hysterectomy, the physician who performs the
hysterectomy must certify in writing that the woman was already sterile prior
to the hysterectomy and state the cause of the sterility;
(c) When there is a life-threatening
emergency situation that requires a hysterectomy in which the physician
determines that prior acknowledgment is not possible, the physician performing
the hysterectomy must certify in writing that the hysterectomy was performed
under a life-threatening emergency situation in which he or she determined
prior acknowledgment was not possible and describe the nature of the
emergency.
(5) In cases
of retroactive eligibility:
The physician who performs the hysterectomy must certify in writing one of the following:
(a) The
woman was informed before the operation that the hysterectomy would make her
permanently incapable of reproducing;
(b) The woman was previously sterile and
states the cause of the sterility;
(c) The hysterectomy was performed because of
a life-threatening emergency situation in which prior acknowledgment was not
possible and describes the nature of the emergency.
(6) Do not use the Consent to Sterilization
form (DMAP 742A or B) for hysterectomies.
(7) Submit a copy of the Hysterectomy consent
form with the claim.
(8)
Sterilization Male & Female: A copy of a properly completed Consent to
Sterilization form (DMAP 742 A or B), the consent form in the federal brochure
DHHS Publication No. (05) 79-50062 (Male), DHHS Publication No. (05) 79-50061
(Female) or another federally approved form must be submitted to the Division
for all sterilizations. The original consent form must be retained in the
clinical records. Prior authorization is not required.
(9) Voluntary Sterilization:
(a) Consent for sterilization must be an
informed choice. The consent is not valid if signed when the client is:
(A) In labor;
(B) Seeking or obtaining an abortion;
or
(C) Under the influence of
alcohol or drugs.
(b)
Ages 15 years or older who are mentally competent to give informed consent:
(A) At least 30 days, but not more than 180
days, must have passed between the date of the informed written consent (date
of signature) and the date of the sterilization except:
(i) In the case of premature delivery by
vaginal or cesarean section the consent form must have been signed at least 72
hours before the sterilization is performed and more than 30 days before the
expected date of confinement;
(ii)
In cases of emergency abdominal surgery (other than cesarean section), the
consent form must have been signed at least 72 hours before the sterilization
was performed.
(B) The
client must sign and date the consent form before it is signed and dated by the
person obtaining the consent. The date of signature must meet the above
criteria. The person obtaining the consent must sign the consent form anytime
after the client has signed but before the sterilization is performed. If an
interpreter is provided to assist the individual being sterilized, the
interpreter must also sign the consent form on the same date as the client;
(C) The client must be legally
competent to give informed consent. The physician performing the procedure, and
the person obtaining the consent, if other than the physician, must review with
the client the detailed information appearing on the Consent to Sterilization
form regarding effects and permanence of the procedure, alternative birth
control methods, and explain that withdrawal of consent at any time prior to
the surgery will not result in any loss of other program
benefits.
(10)
Involuntary Sterilization - Clients who lack the ability to give informed
consent and are 18 years of age or older:
(a)
Only the Circuit Court of the county in which the client resides can determine
that the client is unable to give informed consent;
(b) The Circuit Court must determine that the
client requires sterilization;
(c)
When the court orders sterilization, it issues a Sterilization Order. The order
must be attached to the billing invoice. No waiting period or additional
documentation is required.
(11) Submit the Consent to Sterilization Form
(DMAP 742 A or B) along with the claim. The Consent to Sterilization form must
be completed in full:
(a) Consent forms
submitted to the Division without signatures and/or dates of signature by the
client or the person obtaining consent are invalid;
(b) The client and the person obtaining
consent may not sign or date the consent retroactively;
(c) The performing physician must sign the
consent form. The date of signature must be either the date the sterilization
was performed or a date following the
sterilization.
Notes
Forms referenced are available from the agency.
Publications: Publications referenced are available from the agency.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025 & 414.065
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