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Early Elective Deliveries Claims Coding

Dear Healthcare Professional Partner,

WellCare Health Plans of New Jersey is committed to improving maternal and child healthcare. On May 8, 2019, Governor Murphy signed Public Law 2019, Chapter 87 (see action below). The intent of the law is to decrease the rate of non-medically indicated Early Elected Deliveries (EEDs) prior to 39 weeks of gestation in the State of NJ.

EEDs are defined as scheduled cesarean sections or medical inductions performed prior to 39 weeks of gestation without medical indication. An EED is not justified solely by maternal request, availability of effective pain management, facility or provider scheduling issues.

The American College of Obstetrics and Gynecology (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) agree that non-medically indicated early elective deliveries performed prior to 39 weeks of gestation carry increase neonatal risks, such as: respiratory distress syndrome, transient tachypnea of the newborn, ventilator use, pneumonia, respiratory failure, neonatal intensive care unit admission, hypoglycemia, 5 minute Apgar score less than 7 and neonatal mortality. In addition to immediate adverse perinatal outcomes, multiple studies have shown increase rates of adverse long-term infant outcomes, such as, increase hospitalizations up to age 18, slower neurologic development, worse cognitive performance, and poorer academic achievement. Unsuccessful inductions may result in a cesarean section, which can lead to infections, bleeding and anesthesia complications for mothers.

Action of Public Law 2019, Chapter 87 (Non-Medically Indicated Early Elective Deliveries) will go into effect on January 1, 2021:

  • Obstetricians, midwives, hospitals and clinics requesting New Jersey Family Care Medicaid reimbursement for a labor and delivery claim are required to report an ICD-10-CM diagnosis code indicating the week of gestation (ICD-10-CM category code Z3A). Claims submitted without a diagnosis code indicating the week of gestation shall be denied payment by WellCare.
  • Any claim reporting a week of gestation ICD-10-CM diagnosis code of less than 39 weeks gestation without one of the diagnosis codes identified by the ICD-10-CM categories: O10; O11; O12; O13; O14; O15; O16; O24; O30; O31; O33; O35; O36; O42; O43; O44; O45; O71; or without one of the diagnosis codes the list shown below shall be denied payment by WellCare.
    O46.002, O46.003, O46.012, O46.013, O46.022, O46.023, O46.092, O46.093, O46.8X2, O46.8X3, O66.6, O67.0, O67.8, O67.9, O68, O69.0XX0, O69.0XX1, O69.0XX2, O69.0XX3, O69.0XX4, O69.0XX5, O69.0XX9, O69.1XX0, O69.1XX1, O69.1XX2, O69.1XX3, O69.1XX4, O69.1XX5, O69.1XX9, O69.2XX0, O69.2XX1, O69.2XX2, O69.2XX3, O69.2XX4, O69.2XX5, O69.2XX9, O69.3XX0, O69.3XX1, O69.3XX2, O69.3XX3, O69.3XX4, O69.3XX5, O69.3XX9, O69.4XX0, O69.4XX1, O69.4XX2, O69.4XX3, O69.4XX4, O69.4XX5, O69.4XX9, O69.5XX0, O69.5XX1, O69.5XX2, O69.5XX3, O69.5XX4, O69.5XX5, O69.5XX9, O69.81X0, O69.81X1, O69.81X2, O69.81X3, O69.81X4, O69.81X5, O69.81X9, O69.82X0, O69.82X1, O69.82X2, O69.82X3, O69.82X4, O69.82X5, O69.82X9, O69.89X0, O69.89X1, O69.89X2, O69.89X3, O69.89X4, O69.89X5, O69.89X9, O69.9XX0, O69.9XX1, O69.9XX2, O69.9XX3, O69.9XX4, O69.9XX5, O69.9XX9, O75.0, O75.1, O76, O98.112, O98.113, O98.12, O98.13, O98.212, O98.213, O98.22, O98.23, O98.712, O98.713, O98.72, O98.73, O99.322, O99.323, O99.324, O99.325

Providers denied payment may request that the denial be re-considered for payment based on medical necessity Providers may seek an appeal through WellCare's Appeals Department within 90 calendar days of a claim denial by sending a summary of the appeal including relevant medical records and member specific information to the Appeals P.O. Box.

Mail or fax Appeals with supporting documentation to:

WellCare Health Plans
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368
FAX: 1-866-201-0657

We thank you for your commitment to the care and wellbeing of our members and to the communities we serve. Please contact us at Provider Services (888) 453-2534, should you have any questions or concerns.

Sincerely,
WellCare Health Plans of New Jersey
WellCare New Jersey

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