PARTNERSHIP HEALTHPLAN OF CALIFORNIA
GUIDELINE / PROCEDURE
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Guideline/Procedure Title: Prenatal & Perinatal Care
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
Original Date: 04/22/1994 (Policy HS-1)
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 02/18/2015
I.
RELATED POLICIES:
A. MCUP3033 - Out of Area Emergency Admissions
B. MCUP3124 - Referral to Specialists (RAF) Policy
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. Perinatal services are defined as pregnancy related services given before and during delivery and for a
period of 60 days following delivery.
B. Comprehensive perinatal services are defined as obstetrical, psychosocial, nutritional and health
education services and related case coordination provided by or under the personal supervision of a
physician during the perinatal period.
C. The Comprehensive Perinatal Services Program (CPSP) was developed by the California Department of
Health Services as an enhanced program of perinatal services to be offered through the Medi-Cal
program and reimbursed at higher rates than traditional obstetrical services. The CPSP provider
certification process is locally administered by the county CPSP Coordinator with final approval by
California Department of Health Services. PHC encourages but does not require providers to be CPSP
certified in order to provide obstetrical and CPSP-like services.
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To describe, define and provide guidelines for the perinatal services to be provided to members of
Partnership HealthPlan of California (PHC)
VI.
GUIDELINE / PROCEDURE:
A. Introduction
1. PHC has two categories of perinatal service providers.
a. Providers certified by the CPSP program or who have an agreement with a CPSP provider for
CPSP support services.
Page 1 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
b. Those who are contracted with PHC to provide comprehensive perinatal services, but who are
not CPSP certified providers, but do provide CPSP like services.
2. PHC’s contract with the California Department of Health Care Services (DHCS) requires contracted
providers to follow current American College of Obstetrics & Gynecology (ACOG) standards as the
minimum standards for services to PHC’s pregnant women. In addition, all obstetrical practitioners
are required to provide a comprehensive initial risk assessment that includes medical nutrition,
health education and psychosocial risks, on all pregnant women at the initiation of pregnancy related
services. Formal re-assessments must be offered in each subsequent trimester and in the postpartum
period. All identified risk conditions must be followed up by interventions designed to eliminate or
remedy the condition or problem in a prioritized manner. Individualized care plans must be
developed to include obstetrical, nutritional, health education and psychosocial interventions when
indicated by identified risk factors. All services/resources provided must be clearly documented on
the Care Plan in the member’s medical record each trimester. Non-CPSP Obstetrical providers must
have an agreement with a certified CPSP provider to provide comprehensive support services. A
non-CPSP provider may choose to use a trained staff person to administer the comprehensive risk
assessments and to make referrals to the CPSP program for interventions and completion of care
plans. A specific billing code is available to bill for administration of assessments by non-CPSP
providers.
B. Program Goals
1. To make comprehensive perinatal services accessible to all pregnant PHC members.
2. To assure all members initiate prenatal care within the first twelve (12) weeks of pregnancy and
pregnant members who are new to the HealthPlan obtain prenatal care within forty-two (42) days
after enrollment in the Plan.
3. To support and expand the range of comprehensive perinatal services provided to PHC members.
4. To strongly encourage obstetrical providers to become CPSP certified providers or to have an
agreement with a CPSP provider to provide support services.
5. To inform all PHC members about the availability of comprehensive perinatal services and the
added benefits of these programs.
6. To assist members with enrollment into comprehensive perinatal services programs.
7. To increase provider awareness of comprehensive perinatal services and the potential benefits for
pregnant members.
C. Perinatal Service Providers
1. In general, perinatal service including antenatal care, labor and delivery services should be provided
by perinatal providers who deliver at the hospital associated with the member’s primary care
physician’s capitated agreement. Exceptions to this include emergency deliveries and hospital
admissions authorized according to the Out of Area Admissions policy, members determined to be
high risk who require the services of a perinatologist, and pregnant women who are not assigned to a
primary care physician because they are in a special member category.
2. OB/GYN providers are expected to refer pregnant women to PHC’s Growing Together Perinatal
Program (GTPP) for voluntary enrollment. Those members determined to be high risk will be
assigned a PHC Care Manager who will provide care management support throughout the
pregnancy.
3. All providers of perinatal services must deliver services in conformance with the following:
a. Current ACOG Standards for Obstetric-Gynecologic Services, (available from the American
College of Obstetricians and Gynecologists, 600 Maryland Avenue, Southwest, Suite 300 East,
Washington, DC 20024).
Page 2 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
b. Newborn Screening Regulations as set forth in Title 17, California Code of Regulations, Section
6500 et seq.
c. Hemolytic disease of the Newborn Requirements as set forth in Title 17, California Code of
Regulations, Section 6510 et seq.
d. Title 22 regulations; Title 17 regulations and all applicable sections of the Health and Safety
Code.
e. The California Prenatal Screening Program.
4. Perinatal service providers include all of the following practitioners for the purpose of providing
perinatal services:
a. Physicians who are general practitioners, family practice physicians, pediatricians, or
obstetrician-gynecologists
b. Certified Nurse Midwives
c. Nurse Practitioners
d. Physician Assistants
e. Registered Nurses, Social Workers, Health Educators, Childbirth Educators, Registered
Dietitians, Perinatal Health Workers, or LVNs
D. Referral Procedures
1. Obstetrical services do not require a Referral Authorization Form (RAF) by the PCP. Members
assigned to a multi-specialty group (Kaiser, or Woodland Health Care) must obtain perinatal
services through that entity. Members assigned to PCPs must obtain obstetrical care from a perinatal
provider associated with the same hospital affiliation as the member’s PCP. Members not assigned
to a PCP may obtain OB services from any provider within their county of residence Members not
assigned to Woodland or Kaiser may obtain OB services from any Medi-Cal contracted provider,
but are strongly encouraged to obtain services from a PHC contracted perinatal provider.
2. It is the responsibility of the perinatal provider to confirm the member's eligibility and PCP
information from the Plan at each visit.
Page 3 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
E. Perinatal Care Guidelines
Requirement
Preconception
Care: physical
exam and medical
history, family
planning and
pregnancy
resources, folic
acid prescription,
cessation of
smoking, alcohol
and drug use, and
domestic
violence/abuse.
Pregnancy Test as
soon as period is
missed or if
woman had
unprotected
intercourse.
Initial history and
physical exam As
soon as pregnancy
is detected. A
prenatal visit
should be available
within one week
upon request.
First Trimester
(0-12 weeks)
Second
Trimester (13-23
weeks)
Third Trimester
(24 – 40 weeks)
Postpartum
Period (delivery
to 8 weeks)
Complete medical
history.
Complete
physical exam
including pelvic
and breast exam.
Prescribe prenatal
vitamin with folic
acid. Establish
estimated date of
delivery.
Page 4 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
Requirement
First Trimester
(0-12 weeks)
Comprehensive
assessment and
reassessments with
referral for support
services as
indicated.
Initial
comprehensive
assessment:
psycho-social,
health education
and nutrition.
Provide and
document referral
to WIC Program.
(Title 42)
Mandatory
referrals:
- Dental Care
- Genetic
Screening
- Family Planning
- WIC
- CHDP
The frequency
and regularity of
scheduled
prenatal visits
should be
sufficient to
enable providers
to accomplish the
following
activities:
1. Monitor the
progression of the
pregnancy
2. Provide
education and
recommended
screening and
interventions
3. Reassure the
mother
4. Assess the
well-being of the
fetus and mother
Prenatal exam
Schedule for low
risk pregnancy.
Women with
medical problems
and younger teens
may require more
frequent visits
Second
Trimester (13-23
weeks)
Reassessment:
psycho-social,
health education
and nutrition
Third Trimester
(24 – 40 weeks)
Reassessment:
psycho-social,
health education
and nutrition
See first trimester
See first trimester
Generally, ACOG
recommends
every four weeks:
same as in first
trimester with the
addition of
questions about
fetal movement
contractions,
leakage of fluid
or vaginal
bleeding.
Generally, ACOG
recommends after
28 weeks, every
two weeks. After
36 weeks, every
week.
Postpartum
Period (delivery
to 8 weeks)
Postpartum
Reassessment:
psycho-social,
health education
and nutrition
Approximately 4
to 6 weeks after
delivery: pelvic
exam, breast and
abdomen exam,
weight, blood
pressure. If
cesarean delivery
or complicated
gestation, an
additional visit
may be needed
within 7-14 days.
Page 5 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
Requirement
First Trimester
(0-12 weeks)
Prenatal exam
Schedule for low
risk pregnancy.
Women with
medical problems
and younger teens
may require more
frequent visits.
5. Detect medical
and psychosocial
complications and
institute indicated
interventions.
Generally, ACOG
recommends
every four weeks,
exam includes
blood pressure,
weight, urine
protein and
glucose,
measurement of
uterus, fetal heart
rate.
Second
Trimester (13-23
weeks)
Third Trimester
(24 – 40 weeks)
Postpartum
Period (delivery
to 8 weeks)
Page 6 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
Requirement
Screening tests
recommended
First Trimester
(0-12 weeks)
Pap smear,
gonorrhea,
Chlamydia
(required for
pregnant women
ages 16-26 yrs)
syphilis,
hepatitis B,
Hematocrit or
hemoglobin
levels, MCV and,
Platelets, blood
type, antibody
screen, rubella
test, urinalysis,
Mantoux TB test,
quantitative
gamma interferon
test (IGRA), HIV
test must be
discussed and
offered. Early
diabetes screen if
family history,
history of large
baby or
gestational
diabetes,
hypertension, or if
mother is 30 years
of age or older.
Second
Trimester (13-23
weeks)
AFP test 15-18
weeks, other
genetic tests as
indicated. An
ultrasound may
be indicated to
determine the due
date or if the baby
is not growing at
the normal rate.
Third Trimester
(24 – 40 weeks)
Diabetes screen,
anemia tests 24-28
weeks, HIV test
may be repeated at
24-28 weeks, tests
for sexually
transmitted
diseases may be
repeated at 32-36
weeks if indicated.
Antibody test
should be repeated
at 28 weeks if RH
negative. Immune
globulin should be
given at this time
if indicated.
Consider screening
for Group B Beta
Strep at 35-37
weeks. Sometimes
a non-stress test or
contraction stress
test may be needed
to assess fetal
well-being.
Postpartum
Period (delivery
to 8 weeks)
Pap smear, anemia
check, birth
control
prescription
Page 7 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
Requirement
Education topics
recommended
First Trimester
(0-12 weeks)
Danger signs,
how to reach your
doctor. Schedule
of visits, use of
safety belts,
Nutrition and
weight gain,
exercise
guidelines,
smoking
cessation, HIV
counseling,
alcohol and
substance abuse
education,
domestic
violence.
Second
Trimester (13-23
weeks)
Pre-term labor
signs, danger
signs, when to
call.
Third Trimester
(24 – 40 weeks)
Kick counts, signs
of labor, labor and
delivery
preparation,
planning for
discharge and
child care,
breastfeeding
education and
resources,
postpartum self
care, family
planning,
resources for home
health after
discharge.
Newborn care,
cord care, jaundice
and circumcision.
Identification of
pediatric provider.
Postpartum
Period (delivery
to 8 weeks)
Family planning,
evaluation of
family planning,
newborn care,
sleep position.
Confirm
participation in
WIC Program
from initial
referral.
Postpartum
depression. Reevaluate breast
feeding concerns.
F. CPSP Case Management Responsibilities
1. The CPSP case manager is expected to plan and ensure the provision of comprehensive perinatal
services, including nutrition, health education, and psychosocial assessments and reassessments,
individualized care plan development, coordination of services, and referrals.
2. The CPSP case manager must assure that the following has been provided to the member and
documented in the medical record:
3. An orientation per CPSP guidelines about the services which have been offered, who will provide
the services, the locations for service delivery, warning signs and symptoms, office procedures, and
purpose of the program.
a. Information about the available adjunctive referral services available to the member.
b. Advice about the member’s rights and responsibilities in accepting or refusing the services
offered.
c. Notification regarding CPSP provider and PHC appeal and grievance policies.
d. An offering of the initial nutrition, health education and psychosocial assessments, and
individualized care plan development, as well as re-assessments in each trimester and postpartum assessments including both individual and group interventions for each service as
recommended in the individualized care plans.
e. Documentation of referrals to services which are not specifically included in the definition of
comprehensive perinatal services, but which are appropriate for the medical and/or psychosocial
health of the member, should be noted in the record by the CPSP case manager.
Page 8 of 9
Guideline/Procedure Number: MCUG3118 (previously
MCQG1017 & QG100117)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 04/22/1994 (Policy HS-1)
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Guideline/Procedure Title: Prenatal & Perinatal Care
4. The CPSP case manager must use orientation, assessments, re-assessments, individual and group
process interventions and family support participation as methods for the provision of
comprehensive perinatal services.
5. The perinatal provider must document his/her assessment of the member's obstetrical status at each
visit.
6. Each component of the individualized care plan should identify risk conditions; prioritize the
member's needs, referrals, and proposed interventions including methods, time frames and outcome
objectives for psychosocial, health education, and nutrition services. The member's needs are to be
reassessed and the individualized care plan revised as necessary at least each trimester and at the
post-partum visit.
7. A member has the right to decline to participate in any part of the Comprehensive Perinatal Services
Program. This should be documented clearly in the medical record.
8. CPSP providers must submit a TAR to PHC for the provision of services in excess of the PHC
maximum frequency allowance for nutrition, psychosocial and health education services, as
established in Title 22, CCR, Section 51504.
9. CPSP providers must submit a list of any staff changes within one month of the change to the county
CPSP Coordinator.
VII.
REFERENCES:
A. Guidelines for Perinatal Care –7th Edition. American College Obstetricians & Gynecologists
VIII.
DISTRIBUTION:
A. Provider Manual
B. OB/Gyn practice sites
C. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES: (HS-1 - 12/10/96; 10/10/97 [name change only]; 02/17/99; 06/21/00, 10/17/01;
06/19/02; 10/20/04; 04/20/05; 05/18/05; 05/17/06; 08/15/07; 08/20/08; 06/17/09; 01/16/13; 03/19/14;
09/17/14; 02/18/2015
PREVIOUSLY APPLIED TO:
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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