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Maternity- Presumptive Eligibility

Date: 12/15/16

Heritage Health (Medicaid):

Presumptive Eligibility for Pregnant Women Women is a process that offers temporary coverage of prenatal care services to pregnant women while their Medicaid applications are pending. The goal of the program is to offer health care to women early in their pregnancies, to improve their health and the healthy of their baby. 

Presumptive members are limited to ambulatory prenatal care only. This includes services related to pregnancy, excluding inpatient hospital services, nursing service, labor and delivery services, and services furnished to deliver or remove an embryo/fetus from the mother, or services following such a provedure. 

Code selection is based on the total number of provided antepartum visits.

  • If only one to three antepartum visits were provided, report the appropriate E/M codes according to CPT guidelines.
  • If four to six visits are provided, report 59425 antepartum care only.
  • If seven or more visits are provided, report 59426 antepartum care only.