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.