CMN_Ultrasound_in_Maternity_Care_Final
|Certificate of Medical Necessity: |[pic] |
|Ultrasounds in Maternity Care | |
| |
|Fax or mail this | |For Pre-Service: Statewide Fax (877) 219-9448 |
|completed form | |For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614 |
| | |For Post-Service Claims: |
| | |Florida Blue |
| | |P.O. Box 1798 |
| | |Jacksonville, FL 32231-0014 |
|Section A |
|Physician Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Requesting Provider | | | |
| |Contact Name: |Phone: |
|Facility Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Location where services will be| | | |
|rendered | | | |
| |Contact Name: |Phone: |
|Member Information |Last Name: |First Name: |
| |Member/Contract Number (alpha and numeric): |Date of Birth: |
|Procedure Information |Procedure Code(s): |Procedure Description: |
| |Diagnosis code(s): |Diagnosis Description: |
| |Date of Service/Tentative Date: |
|Section B |
|Medical Necessity: For detailed information on the criteria that meet the definition of medical necessity for ultrasounds for maternity care, |
|visit the Florida Blue Medical Coverage Guideline website at . Refer to Medical Coverage Guideline 04-76500-01, Ultrasounds in Maternity |
|Care. |
|Section C |
Check ALL boxes that apply:
|What trimester? First Second Third |
|This is: an initial ultrasound. a subsequent ultrasound under the same procedure code |
|If subsequent, enter which ultrasound (second, third…) |
| Yes | No |Is this a two-dimensional (2D), three-dimensional (3D), or four-dimensional (4D) ultrasound to only view the fetus, obtain a picture of |
| | |the fetus or determine the fetal gender? |
|Section D |
Check ALL boxes that apply:
| Yes | No |Is the obstetrical ultrasound examination in the first trimester of pregnancy for a medical reason? |
| | |Check all that apply: |
| | | |
| | |Assessment of fetal anomalies in high-risk individuals |
| | | |
| | | |
| | |Confirmation of cardiac activity |
| | | |
| | | |
| | |Diagnosis or evaluation of multiple gestations |
| | | |
| | | |
| | |Estimation of gestational age |
| | | |
| | | |
| | |Evaluation of maternal pelvic masses and/or uterine abnormalities |
| | | |
| | | |
| | |Evaluation of pelvic pain |
| | | |
| | | |
| | |Evaluation of suspected ectopic pregnancy |
| | | |
| | | |
| | |Evaluation of suspected hydatidiform mole |
| | | |
| | | |
| | |Evaluation of vaginal bleeding |
| | | |
| | | |
| | |Other Describe: |
| | | |
| Yes | No |Is the obstetrical ultrasound examination in the second or third trimester of pregnancy for a medical reason? |
| | |Check all that apply: |
| | | |
| | |Estimation of gestational age |
| | | |
| | | |
| | |Evaluation for premature rupture of membranes and/or premature labor |
| | | |
| | | |
| | |Evaluation of abdominal and pelvic pain |
| | | |
| | | |
| | |Evaluation of cervical insufficiency |
| | | |
| | | |
| | |Evaluation of fetal growth |
| | | |
| | | |
| | |Evaluation of multiple gestation (e.g., growth discrepancy) |
| | | |
| | | |
| | |Evaluation of pelvic mass |
| | | |
| | | |
| | |Evaluation of suspected amniotic fluid abnormalities |
| | | |
| | | |
| | |Evaluation of suspected ectopic pregnancy |
| | | |
| | | |
| | |Evaluation of suspected fetal death |
| | | |
| | | |
| | |Evaluation of suspected hydatidiform mole |
| | | |
| | | |
| | |Evaluation of suspected placental abruption |
| | | |
| | | |
| | |Evaluation of suspected uterine abnormality |
| | | |
| | | |
| | |Evaluation of vaginal bleeding |
| | | |
| | | |
| | |Follow-up evaluation of a fetal anomaly |
| | | |
| | | |
| | |Follow-up evaluation of placental location for suspected placental previa |
| | | |
| | | |
| | |Determination of fetal presentation |
| | | |
| | | |
| | |Other Describe: |
| | | |
Additional Comments:
| |
| |
| |
|I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical |
|Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation |
|necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a |
|guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan |
|benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to |
|comply with such request may be a basis for the denial of a claim associated with such services. |
|Ordering Physician’s Signature: |Date: |
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