Sterilization and hysterectomy are covered women’s health care services for Medicaid enrollees.
A properly completed Sterilization Consent Form (HHS-687) is required for all sterilization-related claims. This includes hospital claims and professional services (surgeon and anesthesia).
All other requirements and instructions for the Sterilization Consent Form must be followed to ensure the consent form is valid. Please see the Washington Apple Health (Medicaid) Sterilization Billing Guide, Appendix A: Consent Form Instructions, for additional information.
Hysterectomy also requires a completed, valid consent form, and all inpatient services require prior authorization. A sterilization consent form is a separate form and is not the correct form for hysterectomies. The Hysterectomy Consent Form (HCA 13-365) is the correct, required form for hysterectomies. Please see the Washington Apple Health (Medicaid) Physician-Related Services/Health Care Professional Services Billing Guide, Hysterectomies section, for additional information.
CHPW will not pay for sterilization or hysterectomy services without a consent form. Payment will be reduced if a valid sterilization or hysterectomy claim does not have a completed, signed consent form.
As stated in the Washington Apple Health (Medicaid) Sterilization Billing Guide:
“For inpatient claims, the hospital must indicate on the claim all charges that are associated with the sterilization on their own line with the appropriate revenue code as noncovered.
“Note: When labor/delivery (including C-section) and a sterilization are performed during the same hospital stay, federal match is not available for the sterilization-related costs if the sterilization did not comply with the informed consent requirement. HCA pays for the labor/delivery (including C-section) only.”
For purposes of this communication, use of “sterilization” in the above quote from the HCA billing guide includes hysterectomy.
Please see the CHPW Provider Manual, “Women’s Health Care” section, for more information. Consent forms are available on our Provider Forms & Tools webpage, under “Claims.”
If you have any questions or need assistance, please contact [email protected] .
Community Health Plan of Washington (CHPW) was founded in 1992 by Washington’s community health centers. CHPW is committed to Washington's health. To enroll in a Community Health Plan of Washington Apple Health (Medicaid), Medicare Advantage, or Individual & Family Cascade Select plans, you must be eligible and live in the service areas. This is not a complete description of benefit. Please contact us for more information.
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