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Application For Comprehensive Prenatal Care Service Provider Participation

In New York State's Prenatal Care Assistance Program

Application Information

1.	Name of Applicant or Applicant Organization
2.	Address
		Phone (         ) ____________________ Ext. ________
3.	Medicaid Provider #
4.	Executive Director/Admin. (Name & Title)
		Phone (         ) ____________________ Ext. ________
5.	Program Contact Person (Name & Title)
		Phone (         ) ____________________ Ext. ________
6.	Check types of prenatal care program comprising your comprehensive prenatal care service system: Diagnostic & Treatment Center Hospital OPD, Satellite, etc. City or County Health Agency Private MD Group Private Solo MD Private CNM, SOLO or Group

7.	Application is intended to secure participation of more than one state-certified Article 28 governing authority: ____ yes; ____ no. If yes, attach listing of organizations and letters of agreement or intent to participate with a brief description of the roles and responsibilities of each organization.
8.	Primary prenatal care will be provided by private practitioner MD and/or CNM subcontractors: ____ yes; ____ no. If yes, attach subcontract or letter of intent for each provider, including Medicaid provider number.

9.	Attach brief description of applicant's service catchment area by minor civil division, zip code, primary care analysis area or combinations of same.
10.	Indicate the availability of Part 85.40 required services:
	On-site By Referral Prenatal Clinical Visits _____ _____ Laboratory Tests _____ _____ Diagnostic Procedures _____ _____ Specialty Medical Services _____ _____ Care Coordination _____ _____ Nutrition Services _____ _____ Health Education _____ _____ Psychosocial Services _____ _____ After-hours Consultation _____ _____ Emergency Room Care _____ _____	On-site By Referral Inpatient Antepartum Care _____ _____ Delivery Facility _____ _____ Level III Delivery Facility _____ _____ Postpartum Care _____ _____ Family Planning* _____ _____ Dental Services _____ _____ Mental Health and Related Social Services _____ _____ Home Care _____ _____ Pharmacy _____ _____ Pediatric Ambulatory Services _____ _____
* Title 10 NYCRR Section 753 defines family planning services to mean the planning and spacing of children by medically acceptable methods and does not include the performance of abortion.
11.	Complete Table 1 on page 3 which summarizes information on sites and practitioners comprising the primary medical service system.
Table 1: Prenatal Sites/Practitioner Profile

Name and address of each Article 28 prenatal service site	Days and hours of services	Check types of staff rendering prenatal medical services.
		______ OB-GYN ______ Other MD ______ Licensed Midwife ______ PA ______ NP
		______ OB-GYN ______ Other MD ______ Licensed Midwife ______ PA ______ NP
		______ OB-GYN ______ Other MD ______ Licensed Midwife ______ PA ______ NP
		______ OB-GYN ______ Other MD ______ Licensed Midwife ______ PA ______ NP
		______ OB-GYN ______ Other MD ______ Licensed Midwife ______ PA ______ NP
Attach additional sheets as necessary

12.	Estimate the number of Medicaid-eligible service recipients (with household incomes up to 200% of the federal poverty level) expected to enroll in applicant system during a calendar year. ____________
13.	Qualified Provider/Presumptive Eligibility
	Check items below to indicate status of applicant's preparation to apply for enrollment as a Qualified Provider (QP) in order to determine Medicaid presumptive eligibility (PE) for pregnant women:
	Yes No Responsible Staff a. Staff at sites have completed training in presumptive eligibility - If yes, indicate date completed _____________________ - If no, when do you expect training to be completed? _____________________       b. Identify responsible staff who will/have complete(d) the training       c. If designated staff have completed the on-line QP training, have you submitted the QP application to SDOH?
	The web address for the on-line PE training is www.bsc-cdhs/org/qpt . A QP application may not be submitted to DOH until the on-line training is completed. The QP application may be obtained at www.nyhealth.gov/health_care/Medicaid/program/index.htm .
14.	Outreach
	Provide operational plan by which applicant will engage in community outreach to identify specific high-risk groups, barriers to early prenatal care and plans to reach unserved pregnant women and reduce barriers. Show how plan will facilitate early entry, reflect linkages with community-based resources and disseminate information on available services and initial enrollment procedures. (Limit 1 page).
15.	Risk Assessment
	Yes No a. A standardized, written risk assessment tool is used in the care of all women. Attach copy of tool and/or standard prenatal record. _____ _____ b. All risk factors are linked to the plan of care and documented in the medical record. _____ _____
16.	HIV Counseling and Testing Onsite
	All comprehensive service providers shall have a confidential program of HIV counseling and testing for all women. Submit policies and procedures regarding provision of HIV pretest counseling for prenatal clients with clinical recommendation for HIV testing. All clients who are HIV tested should receive HIV posttest counseling.
	List Locations for Counseling & Testing
	_______________________________________________________________________________________________________________________________________________________
	_______________________________________________________________________________________________________________________________________________________
	_______________________________________________________________________________________________________________________________________________________
17.	Coordination of Care
	In the broadest sense (i.e. beyond the physical exam and diagnostic testing) describe the principal responsibilities and mechanisms for overall care coordination, exchange of information between the primary prenatal care provider and other providers, continued access of client to information and support for obtaining needed medical, nutritional, psychosocial, health education, drug and substance abuse services. Describe follow-up mechanisms for abnormal lab results and to ensure women receive all indicated services. Describe criteria for home visitation. (Limit to 1 page).
18.	Missed Visits
	Applicant care sites have a systematic and documented procedure to contact patients who have missed visits, and to reschedule visits: ____ yes ____ no. Attach copy of procedure.
19.	After Hours Consultation; Emergency Services
	Describe arrangements for 24 hour availability of urgent consultation and emergency services throughout the prenatal, intrapartum and postpartum period.
20.	Nutrition Services
	For each required element of nutrition services, complete the following information:
	Title of Responsible Staff a. Individual nutrition risk assessment including screening for specific nutritional risk conditions at the initial prenatal care visit and continuing reassessment as needed. Attach copy of nutrition assessment tool. _____________________________ b. Professional nutrition counseling, monitoring and follow-up of all pregnant women at nutritional risk. Submit criteria for referral to Registered Dietitian or Nutritionist. _____________________________ List any sites where this service is not available onsite: Site _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Referral Source _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ c. Who is responsible for enrolling eligible women in the supplemental Food Program for Women, Infant and Children (WIC) at the first prenatal visit? Attach description of this process.   __________________________________ d. Summarize WIC arrangements as follows: Prenatal Care Site WIC Immediately On-Site If no, indicate travel time from prenatal care site Yes No
21.	Health and Childbirth Education
	Health and Childbirth Education is provided on-site ____ yes ____ no
	Attach copy of health education checklist/tool.
	Indicate staff responsibility for required elements of maternal education:
	Topics Title of Responsible Staff a. Orientation to procedures at comprehensive care site and expected site of birth including mechanisms for emergency services; __________________________________ b. Rights and responsibilities of the pregnant woman; __________________________________ c. Signs of complication of pregnancy; __________________________________ d. Physical activity and exercise during pregnancy; __________________________________ e. Avoidance of harmful practices and substances including alcohol, drugs, non-prescribed medications and nicotine; __________________________________ f. Sexual activity and sexuality during pregnancy; __________________________________ g. Occupational and environmental issues, concerns; __________________________________ h. Risks of HIV infection and risk reduction behaviors; __________________________________ i. Signs of labor; __________________________________ j. Labor and delivery process; __________________________________ k. Relaxation techniques during labor; __________________________________ l. Obstetrical anesthesia; __________________________________ m. Preparation for parenting including infant development and care; parenting skills and options for feeding; and __________________________________ n. Reinforcement of the need for postpartum and family planning services. __________________________________
22.	Psychosocial Services
	Yes No Title of Responsible Staff a. Psychosocial assessments are routinely conducted by professional staff. Attach copy of psychosocial assessment tool.       b. There are in-house resources for addressing commonly identified problems.       c. What are the most frequently used referral resources for social, economic, psychological, drug and substance abuse and domestic violence problems?
	Problem Area Referral Resources ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
23.	Primary Medical Services
	Care sites have a written protocol covering basic requirements for initial comprehensive assessments and subsequent low-risk and high-risk visits ____ yes ____ no. Attach copy of protocol.
	Access to primary services: the average time from first patient contact to first primary services is ______ weeks. If this varies substantially in a multi-site system, the most timely access is approximately ______ weeks and the greatest delay is approximately ______ weeks.
24.	Laboratory & Diagnostic Testing
	For each required laboratory and diagnostic test listed below, indicate if performed on-site or referred off-site. Attach additional sheets for each site of care.
	Test Procedure Performed On-Site Referred Off-Site Complete blood count _______ _______ Hemoglobin Electropheresis _______ _______ Blood group and Rh determination _______ _______ Irregular antibody screen _______ _______ Rubella antibody titre _______ _______ Syphilis screen _______ _______ Gonorrhea screen _______ _______ Chlamydia screen _______ _______ Pap smear _______ _______ Urinalysis _______ _______ Urine culture _______ _______ Hepatitis B Surface Antigen _______ _______ Alpha-feto protein _______ _______ Tuberculin testing _______ _______ Glucose challenge test _______ _______ Obstetrical Ultrasound _______ _______
	Because the comprehensive prenatal visit rates established for hospitals or diagnostic and treatment centers in this program include payment for laboratory and ultrasound services provided to services recipients, all applicant sites of service must have in place mechanisms which ensure that laboratory and ultrasound services provided by outside vendors are not billed directly to Medicaid by the vendor. Please attach the following items:
	a. A summary of the steps that will be taken to prevent duplicate billing. b. A letter developed for the purpose of informing outside vendors of billing requirements for comprehensive prenatal care service recipients. c. A referral form which clearly identifies your agency as the party responsible for compensating the outside vendor for services provided to comprehensive prenatal care service recipients and which does not include any Medicaid billing information which would allow direct billing to Medicaid by the vendor.
25.	Other Services
	Indicate arrangement for the following services:
	Services On-Site Where Not On-Site Indicate Source of Referral Yes   No  a. Dental       b. Mental Health & Related Social Services       c. Emergency Room Services       d. Home Care       e. Pharmacy       f. Transportation
26.	Hospital Services
	Provide data below on arrangements with hospitals for delivery and medical/obstetrical problems:
	Hospital Level of Perinatal Provider If different from applicant agency, is written agreement in place? Attach copy of each agreement Yes No                                         There continue to be hospitals (approached by applicant) which decline to serve as delivery facilities: ____ yes ____ no. If yes, list non-participating hospitals: ____________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
27.	Informed Consent
	All care sites have policy/procedure and form(s) whereby women are advised of treatment options and render informed choice regarding mode of treatment, care and technological support ____ yes ____ no
28.	Consultation by Specialists; Transfers to Obstetrician
	All care sites without qualified obstetricians must have written protocols designating:
	a. The requirements for consultation with a qualified medical specialist when indicated by specific medical conditions, and b. Situations which require the transfer of the primary responsibility for patient care from a primary care professional who is a general practitioner, family practice physician, physician's assistant, licensed midwife or qualified nurse practitioner to a qualified obstetrician. Attach copy of protocol.
29.	Postpartum Services
	In the applicant's care system, indicate who is responsible for the following required components of postpartum services and attach a copy of the postpartum tool:
	Activity/Service Responsible Staff a. A postpartum visit scheduled not later than 8 weeks after delivery; __________________________________ b. For the interim between delivery and the postpartum visit, a means of contacting the provider in case postpartum questions or concerns arise; __________________________________ c. A specific follow-up mechanism to contact mothers to maximize postpartum visits; __________________________________ d. Identification of any medical, psychosocial, nutritional, alcohol treatment, drug treatment, and educational needs of the mother or infant that are not being met; __________________________________ e. Direction of the mother or other infant caregiver to resources available for meeting such needs and providing assistance in meeting such needs where appropriate; __________________________________ f. Assessment of family planning needs and provision of advice and services or referral where indicated; __________________________________ g. Provision of preconception counseling as appropriate and encouragement of preconception visit prior to subsequent pregnancies for women who might benefit from such visit; __________________________________ h. Referral of infants at risk of physical and developmental delays to the Department of Health?s Infant Health Assessment Program (IHAP). Such infants shall include but not be limited to those whose mothers or who themselves have been diagnosed as Hepatitis B and/or HIV positive; and __________________________________ i. Informing the mother of the availability of expanded Medicaid eligibility for infants up to age one and making appropriate referrals to child health care providers including the Child/Teen Health Plan. __________________________________
30.	Internal Quality Assurance
	Indicate status of applicant's internal quality assurance activities with respect to criteria below and attach written description of quality assurance plan.
	Yes No a. A documented and filed prenatal chart audit is performed quarterly on a target number or proportion of current client records; ______ ______ b. An annual written summary evaluation of all components of such audits is prepared; ______ ______ c. A system for determining patient satisfaction and for resolving patient complaints is functioning; ______ ______ d. A system for developing and recommending corrective actions to resolve identified problems is present, and there is; ______ ______ e. A follow-up process to assure that recommendations and plans of correction are implemented and are effective; and there are; ______ ______ f. Safeguards in effect to maintain patient confidentiality requirements. ______ ______
31.	Assurances
	Applicant, participating sites and perinatal care subcontractors are encompassed in submission of this application and assurances below:
	a. Applicant, care sites and primary care subcontractors shall make available to representatives of the Department of Health any medical records, other records, documentation and reports related to comprehensive prenatal care services. b. Applicant has made certain that the attachment checklist has been completed and that necessary documentation has been filed with this application. c. The signature of an individual authorized to bind the applicant is provided below. d. If applicant is to secure participation of Article 28 or subcontracting entities other than applicant, letters of intent/affiliation which include the signed "Application Assurances" shall be included with the application, affirming the recognition and intent to comply with Part 85.40 requirements by these entities.

I, _________________________________________________________,
    (Name of Authorized Individual)

for and on behalf of __________________________________________,
                             (Applicant Organization)

Signify that applicant and any sites of services agree to abide by the terms of Part 85.40, Part 86 (reimbursement) as applicable, and the requirements/representations associated with this application.

Attachments

Signature ___________________________________________

Title         ___________________________________________    Date   _______________________

Attachment Check List

Reference Point in Application	Description	Check If Attached
7.	Letters of agreement/intent from each Article 28 agency and a brief description of the roles and responsibilities of each organization	_______
8.	Letters of Intent for each MD and licensed midwife subcontractor	_______
9.	Brief description of service catchment area by minor civil division, zip code, primary care analysis area, etc.	_______
14.	Plan for community outreach	_______
15.	Copy of risk assessment tool and/or standard prenatal record	_______
16.	Copy of HIV Counseling and Testing Policies and Procedures	_______
17.	Description of care coordination. Criteria for home visitation.	_______
18.	Procedure for missed visits	_______
19.	Description of arrangements for 24 hour availability of urgent consultation and emergency services.	_______
20.	Copy of nutrition assessment tool. Criteria for referral to RD/nutritionist. Describe WIC enrollment process.	_______
21.	Copy of health education checklist	_______
22.	Copy of psychosocial assessment	_______
23.	Protocol for primary medical services including initial comprehensive assessments and subsequent low-risk and high-risk visits	_______
24.	Summary of steps that will be taken to prevent duplicate billing of laboratory and diagnostic testing	_______
.	Letter informing outside vendors of billing requirements for comprehensive prenatal care service recipients	_______
26.	Copy of written agreement with each hospital used for delivery and medical/obstetrical problems	_______
28.	Copy of protocol for consultation by specialists; transfers to obstetrician	_______
29.	Copy of postpartum tool	_______
30.	Attach description of internal quality assurance plan	_______
31.	If applying to secure participation of Article 28 or subcontracting entities other than applicant, attach letters of intent/affiliation which include the signed "Application Assurances" affirming the recognition and intent to comply with Part 85.40 requirements by these entities.	_______

Prenatal Care Assistance Program (PCAP) Regional Staff

Region	Regional Staff	Address	Phone #	Fax #
Capital Region	Sandra Kuebler Karen Barrett	Capital Region Field Office Frear Bldg. - 4th fl 2 Third Street Troy, NY 12180	518-271-2761	518-271-2776
Western Region	Karen LaGioia	Western Regional Office 335 E. Main St Buffalo, NY 14202	585-423-8073	585-423-8128
Metropolitan Region	Marta Baez	Metropolitan Regional Office 5 Penn Plaza - 4th fl New York, NY 10001	212-417-5450
New Rochelle Region	Reanna Jenkins	New Rochelle Office 145 Huguenot Street New Rochelle, NY 10801	914-654-7194	914-654-4315
Syracuse Region	Maria MacPherson	Syracuse Regional Office 217 S. Salina Street Syracuse, NY 13210	315-426-7639	315-426-7625

Please print this using 1/2 inch margins.

Please send 3 copies of the completed application to:

Perinatal Health Unit
Bureau of Women's Health
New York State Department of Health
Empire State Plaza
Corning Tower, Room 1882
Albany, New York 12237-0621