PARTNERSHIP HEALTHPLAN OF CALIFORNIA
GUIDELINE / PROCEDURE
Policy/Procedure Number: HKUG3120 (previously MPUG3120 &
Lead Department: Health Services
KK QI203)
Policy/Procedure Title: : Prenatal & Perinatal Care for Commercial
External Policy
Members
Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
Approval Signature: Robert Moore, MD, MPH
CREDENTIALING
DEPT. DIRECTOR/OFFICER
Approval Date: 08/19/2015
I.
RELATED POLICIES:
A. HKUP3080 - TAR Process (HK Only)
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. Perinatal services are defined as:
1. Pregnancy related services given before and during delivery and for a period of 60 days following
delivery
2. 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
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To describe, define and provide guidelines for the perinatal services as provided by Partnership HealthPlan of
California (PHC).
VI.
GUIDELINE / PROCEDURE:
A. PHC follows current American College of Obstetrics & Gynecology (ACOG) standards as the minimum
standards for services to PHC’s pregnant women.
B. Program Goals
1. To make 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 perinatal services provided to PHC members.
Page 1 of 7
Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
C. Perinatal Service Providers
1. Perinatal services including antenatal care, labor and delivery services must be provided by perinatal
service providers who deliver at an in-network contracted hospital.
2. 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).
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.
3. 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. General obstetrical services do not require a referral or completion of a Referral Authorization Form
(RAF) by the PCP.
a. It is the responsibility of the perinatal provider to confirm the member's eligibility and PCP
information from the Plan at each visit.
b. Refer to PHC TAR Process for further details.
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Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
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.
Comprehensive
assessment and
reassessments with
referral for support
services as indicated.
First Trimester
(0-12 weeks)
Complete medical
history. Complete
physical exam
including pelvic
and breast exam.
Prescribe prenatal
vitamin with folic
acid. Establish
estimated date of
delivery.
Initial
comprehensive
assessment:
psycho-social,
health education
and nutrition.
Provide and
document referral
to WIC Program.
(Title 42)
Second
Trimester (13-23
weeks)
Third Trimester
(24 – 40 weeks)
Reassessment:
psycho-social,
health education
and nutrition
Reassessment:
psycho-social,
health education
and nutrition
Postpartum Period
(delivery to 8 weeks)
Postpartum
Reassessment: psychosocial, health education
and nutrition
Page 3 of 7
Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
Requirement
First Trimester
(0-12 weeks)
Comprehensive
assessment and
reassessments with
referral for support
services as indicated.
Continued
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 wellbeing of the fetus
and mother
5. Detect medical
and psychosocial
complications and
institute indicated
interventions.
Prenatal exam
Schedule for low risk
pregnancy. Women
with medical
problems and
younger teens may
require more frequent
visits
Second
Trimester (13-23
weeks)
Third Trimester
(24 – 40 weeks)
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)
4 to 6 weeks after
delivery: pelvic exam,
breast and abdomen
exam, weight, blood
pressure. If cesarean
delivery an additional
visit may be needed
within 7-14 days.
Page 4 of 7
Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
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,
Continued
Generally, ACOG
recommends
every four weeks,
exam includes
blood pressure,
weight, urine
protein and
glucose,
measurement of
uterus, fetal heart
rate.
Pap smear,
gonorrhea,
Chlamydia
(required for
pregnant women
ages 16-26 yrs)
syphilis,
hepatitis B,
Hemoglobin,
Hematocrit, MCV,
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.
Screening tests
recommended
Second
Trimester (13-23
weeks)
Third Trimester
(24 – 40 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.
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 nonstress 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 5 of 7
Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
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)
Postpartum Period
(delivery to 8 weeks)
Kick counts, signs
of labor, labor and
delivery
preparation,
planning for
discharge and
child care,
breastfeeding
education and
resources,
postpartum selfcare, family
planning,
resources for
home health after
discharge.
Newborn care,
cord care,
jaundice and
circumcision.
Identification of
pediatric provider.
Family planning,
evaluation of family
planning, newborn care,
sleep position. Confirm
participation in WIC
Program from initial
referral.
Postpartum depression.
Re-evaluate breast
feeding concerns.
VII.
REFERENCES:
A. Guidelines for Perinatal Care – 6th Edition. American College Obstetricians & Gynecologists
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. OB/Gyn practice sites
C. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES:
Healthy Kids
08/20/08; 01/16/13; 08/19/15
PREVIOUSLY APPLIED TO:
Healthy Families:
MPUG3120 - 01/16/2013 to 03/01/2013
Page 6 of 7
Policy/Procedure Number: : HKQG1037 (previously
Lead Department: Health Services
MPUG3120 & KK QI203)
☒External Policy
Policy/Procedure Title: Prenatal & Perinatal Care for
Commercial Members
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
*********************************
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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