3.1 Certification
Requirements
A birthing center which meets
the following criteria may be designated as an authorized TRICARE
institutional provider:
3.1.1 The predominant type of service
and level of care rendered by the center is otherwise covered.
3.1.2 The center
is licensed to operate as a birthing center where such license is
available, or is specifically licensed as a type of ambulatory health
care facility where birthing center specific license is not available,
and meets all applicable licensing or certification requirements
that are extant in the state, county, municipality, or other political
jurisdiction in which the center is located. A freestanding or institutional-affiliated
birthing center may be considered for status as an authorized institutional provider.
3.1.3 The center
is accredited by a nationally recognized accreditation organization.
The following organizations are acknowledged as acceptable accreditation
organizations by TRICARE; however, the contractors may contact the
Medical Benefits and Reimbursement Section (MB&RS) to determine
if other accreditation organizations can be recognized:
3.1.3.1 The Joint
Commission, 1 Renaissance Blvd., Oakbrook Terrace, IL 60181, telephone
(630) 792-5290.
3.1.3.2 The Accreditation
Association for Ambulatory Health Care, Inc., 3201 Old Glenview
Road, Suite 300, Wilmette, IL 60091, telephone (847) 853-6060.
3.1.3.3 The Commission
for the Accreditation of Birth Centers, P.O. Box 34, East Greenville,
PA 18041, telephone (215) 679-4833.
3.1.4 The center
has entered into a participation agreement with TRICARE in which
the center agrees, in part, to:
3.1.4.1 Participate
in TRICARE and accept payment for maternity services based upon
the reimbursement methodology for birthing centers;
3.1.4.2 Collect
from the beneficiary only those amounts that represent the beneficiary’s
liability under the participation agreement and the reimbursement
methodology for birthing centers, and the amounts for services and
supplies that are not a benefit.
3.1.4.3 Permit
access by the Director, Defense Health Agency (DHA), or a designee,
to the clinical record of any beneficiary, to the financial and
organization records of the center, and to reports of evaluations
and inspections conducted by state or private agencies or organizations;
3.1.4.4 Submit
claims first to all health benefit and insurance plans primary to
TRICARE to which the beneficiary is entitled and to comply with
the double coverage provisions;
3.1.4.5 Notify
the contractors in writing within 7 days of the emergency transport
of any beneficiary from the center to an acute care hospital or
of the death of any beneficiary in the center;
3.1.4.6 A birthing
center shall not be a TRICARE authorized institutional provider
and benefits shall not be paid for any service provided by a birthing
center before the date the participation agreement is signed by
the contractor.
3.2 TRICARE Birthing Center Standards
3.2.1 Environment.
The center has a safe and sanitary environment, properly constructed, equipped,
and maintained to protect health and safety and meets the applicable
provisions of the “Life Safety Code” of the National Fire Protection
Association.
3.2.2 Policies and procedures. The center has a written
administrative, fiscal, personnel and clinical policies and procedures
which collectively promote the provision of high-quality maternity
care and childbirth services in an orderly, effective, and safe
physical and organizational environment.
3.2.3 Informed consent. Each beneficiary
admitted to the center will be informed in writing at the time of
admission of the nature and scope of the center’s program and of
the possible risks associated with maternity care and childbirth
in the center.
3.2.4 Beneficiary care. Each woman
admitted will be cared for by or under the direct supervision of
a specified physician or a specific certified nurse-midwife who
is otherwise eligible as an individual professional provider.
3.2.5 Medical
direction. The center has written Memoranda Of Understanding (MOU)
for routine consultation and emergency care with an obstetrician-gynecologist
who is certified or is eligible for certification by the American
Board of Obstetrics and Gynecology or the American Osteopathic Board of
Obstetrics and Gynecology and with a pediatrician who is certified
or eligible for certification by the American Board of Pediatrics
or by the American Osteopathic Board of Pediatrics, each of whom
have admitting privileges to at least one back-up hospital. In lieu
of a required MOU, the center may employ a physician with the required
qualification. Each MOU must be renewed annually.
3.2.6 Admission
and emergency care criteria and procedures. The center has written
clinical criteria and administrative procedures, which are reviewed
and approved annually by a physician related to the center for exclusion
of a woman with a high-risk pregnancy from center for management of
maternal and neonatal emergencies.
3.2.7 Emergency treatment. The center
has a written MOU with at least one backup hospital which documents
that the hospital will accept and treat any woman or newborn transferred
from the center who is in need of emergency obstetrical or neonatal
medical care. In lieu of this MOU with a hospital, a birthing center
may have an MOU with a physician, who otherwise meets the requirements as
an individual professional provider, and who has admitting privileges
to a back-up hospital capable of providing care for critical maternal
and neonatal patients as demonstrated by a letter from that hospital
certifying the scope and expected duration of the admitting privileges
granted by the hospital to the physician. The MOU must be renewed
annually.
3.2.8 Emergency medical transportation. The center
has a written MOU with at least one ambulance service which documents
that the ambulance service is routinely staffed by qualified personnel
who are capable of the management of critical maternal and neonatal
patients during transport and which specifies the estimated transport
time to each backup hospital with which the center has arranged
for emergency treatment. Each MOU must be reviewed annually.
3.2.9 Professional
staff. The center’s professional staff is legally and professionally
qualified for the performance of their professional responsibilities.
3.2.10 Medical
records. The center maintains full and complete written documentation
of the services rendered to each woman admitted and each newborn
delivered. A copy of the informed consent document which contains
the original signature of the beneficiary, signed and dated at the time
of admission, must be maintained in the medical record of each beneficiary.
3.2.11 Quality
assurance. The center has an organized program for quality assurance
which includes, but is not limited to, written procedures for regularly
scheduled evaluation of each type of service provided, of each mother
or newborn transferred to a hospital, and of each death within the facility.
3.2.12 Governance
and administration. The center has a governing body legally responsible
for overall operation and maintenance of the center and a full-time
employee who has authority and responsibility for the day-to-day
operation of the center.