Partnering With You to Ensure Timely Prenatal and Postpartum Visits

Date: August 23, 2024
Attention: Obstetric Care Providers

Prenatal and Postpartum Visits 

Texas Children’s Health Plan (TCHP) encourages OB/GYNs and other providers to take measures to ensure that your patients, our members, are receiving timely prenatal and postpartum visits. TCHP is committed to optimizing the quality of obstetric care provided to members during pregnancy and the postpartum period. Together, we can support healthy pregnancies, reduce maternal mortality and improve neonatal outcomes. 

OB/GYNs and other providers are encouraged to share this communication with their staff and implement office management protocols that prioritize scheduling of timely prenatal and postpartum appointments.

Early Prenatal Care and Timely Postpartum Care

Providing early prenatal care, starting in the 1st trimester:

• is a recognized quality metric

• promotes healthy pregnancy outcomes

• optimizes the potential for early recognition and intervention for high risk maternal and fetal conditions

Postpartum care tailored to the needs of the member:

• between 7 and 84 days is a recognized quality metric

• is recommended within the first 3 weeks after delivery, followed by ongoing care as needed

  • note: 12 months of postpartum coverage begins the month after a pregnancy has ended. Members have this coverage even if they do not appear to be active in Epic.

Coverage Details

• Pregnant Medicaid and CHIP members will continue to receive postpartum coverage in their existing type program (TP)/type of assistance (TA) and risk group.

• HHSC is not creating new TPs/TAs or risk groups to implement 12 month postpartum coverage. Therefore, reinstated members will return to their previous TP/TA and risk group for the remainder of their 12-month postpartum coverage period.

  • For example: Most members will remain in Pregnant Women’s Medicaid under TP 40 and CHIP under TA 84.

• CHIP members will not need to pay another enrollment fee to get 12-month postpartum coverage.

  • The full array of Medicaid or CHIP covered services remain available in the 12-month postpartum period, including, but not limited to:

  • Regular checkups with the doctor.
  • Prescription drugs and vaccines.
  • Hospital care and services.
  • X-rays and lab tests.
  • Vision and hearing care.
  • Access to medical specialists and mental health care.
  • Treatment of special health needs and pre-existing conditions.

How TCHP Supports Members

TCHP is working to:

• educate on the importance of timely, consistent care during pregnancy, postpartum and in the fourth trimester

• identify and address barriers to care

• assist with care navigation including appointment scheduling, transportation, referrals and care coordination 

Partnership for Quality Care

TCHP encourages OB/GYNs and other providers to partner with us to emphasize the importance of care before and after birth and accommodate scheduling timely care for all patients. Thoughtful consideration of innovative models of care including group prenatal care and hybrid models integrating telemedicine where clinically appropriate may increase access to care and member satisfaction.

Potential Provider Incentives: In order to assist and recognize providers who ensure our members receive timely, quality prenatal and postpartum care, providers may be eligible to participate in a Provider Incentive Program. Providers must qualify to participate in this program based on their panel size and network participation. If you are interested in learning more, please contact your assigned Provider Relations Liaison (PRL). If you are not aware of your assigned PRL, please email providerrelations@texaschildrens.org. We are excited to offer this to our network and encourage your participation.

How this impacts OB/GYNs and other providers:

TCHP asks providers to please:

• schedule all required appointments in accordance with recommendations for quality obstetric care

  • prioritizing individual member needs including but not limited to clinical risk factors and gestational age

• submit all claims timely, as soon as services are rendered

• use the appropriate codes on your claims to reflect the services provided, particularly for prenatal and postpartum visits

TCHP would like OB/GYNs and other providers to be aware that we actively assist members who fall behind or are in need of prenatal or postpartum care. With expressed member consent, TCHP Field Relation Coordinators (FRCs) overcome barriers to care by:

• facilitating appointment scheduling with member’s selected provider

• assist with transportation or other needs a member may encounter that prevents them from keeping their appointment. Click here for information on member transportation services.

Next steps for providers: We kindly ask that OB/GYNs and other providers submit claims timely so that they are compliant with the Healthcare Effectiveness Data and Information Set (HEDIS) measures. In doing so, you’re continuing to provide great care to our members while also having the opportunity to participate in the Provider Incentive Program. We ask that providers use appropriate codes to reflect the services for prenatal and postpartum visits. Additional information on appropriate coding is shown below:

Timeliness of Prenatal Care (TOPC)

The percentage of deliveries that received a prenatal care visit in the first trimester, on or before the enrollment start date, or within 42 days of enrollment.

* codes for supervision of normal pregnancies.
† codes for supervision of conditions affecting pregnancy
NOTE: The prenatal visits must be billed with modifier TH.

Postpartum Care (PPC)

The percentage of deliveries that had a postpartum visit on or between 7 to 84 days after delivery.

Following the passing of House Bill 12, postpartum coverage for Medicaid and CHIP recipients has been extended to 12 months. Click here for more information.

* 59430 is reimbursable once per pregnancy by Texas Medicaid and must be used for a visit between 7-84 days following delivery. Subsequent postpartum visits must be billed using E&M codes. Visits solely for staple removal do not qualify for use of 59430.

NOTE: Both CPT and appropriate ICD-10 codes must be present for claim to be paid. Code Z39.0 is not an applicable HEDIS code for PPC visits.

Click here to view the HEDIS toolkit available for guidance on providing and coding for quality prenatal and postpartum care.

For additional information on the importance of prenatal and postpartum visits, and information to share with patients, providers and staff can visit:

• Promoting Women's Health: A presentation on Promoting Women's Health by Audrey Voss (Clinical Practice Consultant) during the June 2024 TCHP Provider Advisory Group.
• TCHP Healthy Pregnancies Site
• Resources for Obstetric Care Providers
• ACOG Optimizing Postpartum Care
• Healthy Texas Woman
• HB12 One Pager and HB12 FAQ
• HHS Medicaid for Pregnant Women and CHIP Perinatal webpage

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.