Pregnancy Quick Reference Guide for Providers
A Message for Prenatal Providers. Please share with your Pregnancy Care team.
Sunflower Health Plan is committed to achieving the best health outcomes for members during and after their pregnancy. This reference guide is designed to help you better understand the specifications for HEDIS® measures used to close care gaps and let you know about programs and resources to support you and your patients.
Supporting Your Care Prenatal Care
The member's first prenatal visit should occur within the first trimester (by the end of 13th week of pregnancy) or within 42 days of enrollment with Sunflower Health Plan. A visit with a registered nurse will not meet compliance. The visit must be with the following care provider types with a documented diagnosis of pregnancy:
- Primary care provider (PCP)
The member's postpartum visit with a care provider must occur on or between 7 and 84 days after the baby is delivered to close the HEDIS® measure. This visit is an opportunity to:
- Screen the mother for depression, anxiety, substance use, etc.
- Discuss family planning (18-month spacing between pregnancies) and contraception
Using the following codes can reduce the need for chart reviews. Include the following postpartum visit codes when you submit your claims:
- CPT®/CPT211 codes: 57170, 58300, 59430, 99501, 0503F
- Healthcare Common Procedure Coding System (HCPCS) code: G0101
- ICD-10 diagnosis codes: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.
Notification of Pregnancy Form (NOP)
A Notification of Pregnancy (NOP) is an assessment that identifies pregnant members, collects risk information, and automatically enrolls members into the Start Smart for Your Baby program. It also aids in establishing a relationship between the member, provider and health-plan staff, which leads to better maternal and health outcomes.
It is recommended to complete the form during the first prenatal visit and submit electronically through our secure provider portal or fax to 866-681-5125. Fax forms for Sunflower Medicaid are available on our Provider Resources web page.
Our Start Smart for Baby care managers will review the form and use it to support the provider and member during and after the pregnancy.
Makena (17P) is covered for Sunflower members who have had a previous preterm birth or premature rupture of membranes with delivery prior to 37 weeks and have a singleton pregnancy.
Makena (17P) Injections (Z track) should start between 16 weeks, zero days through 27 weeks, six days of pregnancy and continue weekly until 36 weeks 6 days of pregnancy have passed.
Makena (17P) requires a prior authorization before it can be administered. Makena (17P) can be provided through medical benefit or picked up from a pharmacy. If you have questions about Makena (17P), please call us at the number at the end of this bulletin.
Start Smart for Your Baby®
Start Smart promotes education and communication with pregnant members to help ensure a healthy pregnancy and first year of life for their babies. Start Smart offers a range of care management techniques to extend the gestational period and reduce the risks of pregnancy complications, premature delivery and infant disease that can result from high-risk pregnancies.
The program provides educational materials, as well as incentives for completing healthy behaviors, like going to postpartum and well-child visits. (Rewards vary by line of business. Members may learn more in their member portal or handbook.) Potential participants are identified through claims data, eligibility data and notification of pregnancy form.
If you'd like to refer a patient, please complete the Notification of Pregnancy form on the provider portal or call the number at the bottom of this bulletin.
Sunflower Health Plan offers language-access services to members with limited English proficiency by way of in-person and over-the-phone interpretation services. In-person interpretation services can be scheduled for future appointments and over-the-phone interpretation services are available for immediate assistance. Sunflower offers these services free of charge.
To schedule these services, please contact our member services at the number below.
Access to Care (Transportation)
For Sunflower Medicaid Members: Transportation services are available for non-emergency rides to and from healthcare locations, including doctor or therapy visits. Call ModivCare at 1-877-917-8162 at least three days before the appointment.
My Health Pays®
This program rewards healthy activities, such as completing the Notification of Pregnancy form and attending preventive care appointments.
- Sunflower Medicaid members can use their cards at Walmart and to help pay for other items, like utilities and more. Additional information about this program is available on our Healthy Rewards page.
- Ambetter members can learn more in the Ambetter member portal.
Early Periodic Screening, Diagnosis and Treatment (EPSDT)
For Sunflower Medicaid Members Younger than Age 21: The EPSDT Kan Be Healthy program promotes regular well-child, preventive health visits. The program can help care providers identify medical, developmental and social-emotional concerns in children and adolescents younger than 21. Learn more on our Kan Be Healthy/EPSDT web page.
SafeLink Cell Phone Program
Sunflower Medicaid members may receive a free smart phone through SafeLink®. These come with free limited data and voice minutes per month, unlimited texting and free calls to and from Sunflower. Program information is available. Ambetter members also may be eligible and can visit www.safelinkwireless.com to learn more.
Health and Wellness Resources
Members and providers can access wellness and emotional support on our website.
24/7 Nurse Advice Line
Our Nurse Advice Line is ready to answer health questions 24 hours a day. It is staffed with registered nurses. Members can call the relevant number below.
If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Customer Service at:
- Sunflower KanCare Medicaid: 1-877-644-4623 (TTY 711)
- Ambetter from Sunflower Health Plan (Marketplace): 1-844-518-9505 (TTY 1-844-546-9713)
- Allwell from Sunflower Health Plan (Medicare Advantage):
- HMO 1-855-565-9519
- HMO D-SNP 1-833-402-6707
- PPO 1-833-696-0634
- TTY: 711