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.