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July 14, 2006
 
MEDICAID INFORMATION RELEASE MA06-30 
 
TO:                 Physicians, Osteopaths, Mid-level Practitioners, Hospitals, and Ambulatory Surgical Centers
 
FROM:           Leslie M. Clement, Administrator
 
SUBJECT:      STERILIZATION CONSENT FORM REQUIREMENTS
 
The purpose of this Information Release is to answer some of the most frequently asked questions about Idaho Medicaid’s sterilization form requirements and address the most common reasons for claim denials.
 
Idaho Medicaid is required to meet the Centers for Medicare and Medicaid (CMS) requirements for sterilization consent forms. Medicaid cannot cover sterilizations unless a valid, complete, and legible Sterilization Consent Form is received by EDS (Electronic Data Systems). The following are Idaho Medicaid’s sterilization and Consent Form requirements:
 
CONSENT FORM:
·         Providers must use the CMS approved sterilization consent form HW0034. Instructions for ordering the consent form from EDS are available online at:
·         You may also order the forms from EDS by phone at (800) 685-3757, then say “Agent” at the voice prompt.
·         If a provider chooses to use a sterilization consent form other than HW0034, the form must indicate that is it approved by CMS and include text that is identical to the HW0034 form.  
 
CLIENT REQUIREMENTS:
·         The individual to be sterilized must be at least 21 years old at the time the consent was obtained.
·         The individual must be mentally competent.
·         The individual must voluntarily give informed consent in accordance with all the requirements outlined on the sterilization consent form.  
·         At least 30 days, but not more than 180 days, must have passed between the date of consent and the sterilization procedure. For example, if the consent form was signed 5/31/06, the sterilization could not be covered until 7/1/06, because there must be 30 days between consent and sterilization (6/1-6/30). The only exceptions to this requirement are cases of premature delivery or emergency abdominal surgery, which must be documented on the form.
 
SIGNATURE REQUIREMENTS:
The consent form must be complete including all blanks filled in legibly and all appropriate boxes checked. The form must be signed and dated by:
  • the individual to be sterilized, and
  • the interpreter, if one was used, and
  • the person obtaining the consent, and
  • the physician performing the sterilization.
 
PROVIDER HANDBOOK:
This information release does not change the information in any provider handbooks.
 
If you have questions concerning this Information Release, please contact Arla Farmer, Bureau of Medical Care, at (208) 364-1958, by FAX at (208) 332-7285, or by email at farmera@state.id.us
 
Thank you for your continuing participation in the Medicaid Program.
 
LMC/af/sw