DCS Comprehensive Health Plan

Pregnancy Termination

Statement/Purpose

This policy outlines pregnancy termination coverage requirements for Department of Child Safety Comprehensive Health Plan (DCS CHP) members.

Definitions

[N/A]

Policy

DCS CHP covers pregnancy terminations when medically necessary and when strict criteria that conform to DCS and AHCCCS requirements are met.

All pregnancy terminations require Prior Authorization (PA) and supporting documentation.

All pregnancy termination requests are reviewed by the Chief Medical Officer (CMO) or designee, except in cases of medical emergencies. In the case of a medical emergency, documentation is provided within two working days of the procedure.

Pregnancy terminations are covered when one or more of the following criteria are met:

• Pregnant child/youth is at risk of death unless the pregnancy is terminated, because of an underlying physical disorder, physical injury, or physical illness; including, a life endangering physical condition caused by or arising from the pregnancy itself;

• Pregnancy is a result of rape or incest; or

• Pregnancy termination is medically necessary according to the medical judgment of a licensed physician, who attests that continuation of the pregnancy could reasonably be expected to pose a serious physical or behavioral health problem for the pregnant member by:

  • creating a serious physical or behavioral health problem for the pregnant member;

  • seriously impairing a bodily function of the pregnant member;

  • causing dysfunction of a bodily organ or part of the pregnant member;

  • exacerbating a health problem of the pregnant member; or

  • preventing the pregnant member from obtaining treatment for a health problem.

Mifepristone (Mifeprex or RU-486) is not a postcoital emergency oral contraceptive.

Providers must follow Food and Drug Administration (FDA) medication guidance for the use of medications in pregnancy termination.

The administration of medications for the purposes of inducing intrauterine pregnancy termination is covered by DCS CHP.

Pregnancy termination by surgery is recommended in cases when medications are used and fail to induce termination of the pregnancy.

If the duration of the pregnancy is unknown or ectopic pregnancy is suspected, current standards of care per ACOG guidelines is expected.

Except in the event of a medical emergency, PA is required for ALL pregnancy terminations and must include qualifying diagnosis/condition. PAs for pregnancy terminations are reviewed by the DCS CHP Chief Medical Officer or designee. In the event of a medical emergency, all documentation must be submitted by the physician to DCS CHP within 2 working days of the procedure.

DCS CHP reports to AHCCCS on pregnancy terminations as required.

Procedure

All pregnancy terminations require Prior Authorization (PA). When a PA request is received, Utilization Management staff contact the provider within 24 hours to confirm the qualifying diagnosis/condition.

PA requirements for pregnancy terminations include submission of:

• AHCCCS Certificate of Necessity for Pregnancy Termination form completed by the attending physician to certify that that in the physician’s professional judgment the criteria for pregnancy terminations outlined above was met;

• Copy of the clinical information, including all relevant laboratory, radiology, consultations or other testing that support justification/medical necessity for pregnancy termination;

• Documentation that the incident was reported to the proper authorities in the case of rape or incest, including the name of the agency to which it was reported, the report number (if available), and the date the report was filed (this documentation requirement is waived if the treating physician certifies that, in his or her professional opinion, the member was unable, for physical or psychological reasons, to comply with the requirement;

• Copy of written consent with dated signature of the pregnant member’s parent or custodial agency representative to the termination procedure OR a court order if the youth is under 18, or is 18 and older and considered an incapacitated adult (ARS§ 14-5101).

Additional documentation required after the procedure or for submission to AHCCCS include:

• A copy of the Prior Authorization form and associated documents (see above);

• A copy of the verification of Diagnosis by Contractor for a Pregnancy Termination request;

• In the case of rape or incest, a copy of the official incident report or report number, unless the physician certifies in his or her professional opinion the member was unable for physical or psychological reasons to comply with the requirement to report the rape and/or incest to the authorities;

• A copy of documentation confirming pregnancy termination occurred;

• In situations where the termination was conducted in an emergency and/or lifesaving situation; and a copy of the clinical information, including all relevant laboratory, radiology, consultations or other testing that support justification/medical necessity for pregnancy termination;

• Additional documentation as required when medications are used for pregnancy termination including:

  • Name of the medications used;

  • Date medications are administered;

  • Duration of pregnancy in days; and

  • The date any additional medications were given (unless a complete abortion was already confirmed).

DCS CHP members undergoing pregnancy termination or considering pregnancy termination are referred to DCS CHP System of Care and/or care management for care coordination as appropriate. These members may also be referred to Children’s Rehabilitative Services (CRS) if applicable.