Oregon Maternity Case Management
Administrative Rules

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 410-130-0595 Maternity Case Management (MCM)

(1) The primary purpose of the Maternity Case Management (MCM)

program is to optimize pregnancy outcomes, including reducing the

incidence of low birth weight babies. MCM services are tailored to the

individual client needs. These services are provided face-to-face,

unless specifically indicated in this rule, throughout the client’s

pregnancy.

(2) This program:

(a) Is available to all pregnant clients receiving Medical Assistance

Program coverage;

(b) Expands perinatal services to include management of health,

economic, social and nutritional factors through the end of pregnancy

and a two-month postpartum period;

(c) Must be initiated during the pregnancy and before delivery;

(d) Is an additional set of services over and above medical

management of pregnant clients;

(e) Allows billing of intensive nutritional counseling services.

(3) Any time there is a significant change in the health, economic,

social, or nutritional factors of the client, the prenatal care provider

must be notified.

(4) Only one provider may provide MCM services to the client at a

time. The provider must coordinate care to ensure that duplicate

claims for MCM services are not submitted to the Division of Medical

Assistance Programs (DMAP).

(5) Definitions:

(a) Case Management -- An ongoing process to assist and support

an individual pregnant client in accessing necessary health, social,

economic, nutritional, and other services to meet the goals defined in

the Client Service Plan (CSP)(defined below);

(b) Case Management Visit -- A face-to-face encounter between a

Maternity Case Manager and the client that must include two or more

specific training and education topics, address the CSP and provide

an on-going relationship development between the client and the

visiting provider. The visit occurs in the client’s home unless

documentation of extenuating circumstances indicates that the

encounter must be conducted elsewhere;

(c) Client Service Plan (CSP) -- A written systematic, client

coordinated plan of care which lists goals and actions required to

meet the needs of the client as identified in the Initial Assessment

(defined below) and includes a client discharge plan/summary;

(d) High Risk Case Management -- Intensive level of services

provided to a client identified and documented by the Maternity Case

Manager or prenatal care provider as being high risk;

(e) High Risk Client -- A client who has a current (within the last year)

documented alcohol, tobacco or other drug (ATOD) abuse history, or

who is 17 or under, or has other conditions identified in the Initial

Assessment or during the course of service delivery;

(f) Home/Environmental Assessment -- A visit to the client's primary

place of residence to assess the health and safety of the client's living

conditions;

(g) Initial Assessment -- Documented, systematic collection of data

with planned interventions as outlined in a CSP to determine current

status and identify needs and strengths in physical, psychosocial,

behavioral, developmental, educational, mobility, environmental,

nutritional, and emotional areas;

(h) Nutritional Counseling -- Intensive nutritional counseling for clients

who have at least one of the conditions listed under Nutritional

Counseling (14)(a)(A-I);

(i) Prenatal/Perinatal care provider -- The physician, licensed

physician assistant, nurse practitioner, certified nurse midwife, or

licensed direct entry midwife providing prenatal or perinatal (including

labor and delivery) and/or postnatal services to the client;

(j) Telephone Case Management Visit -- A non-face-to-face

encounter between a Maternity Case Manager and the client

providing identical services of a Case Management Visit (G9012).

(6) Maternity Case Manager Qualifications:

(a) Maternity Case Managers must be currently licensed as a:

(A) Physician;

(B) Physician Assistant;

(C) Nurse Practitioner;

(D) Certified Nurse Midwife;

(E) Direct Entry Midwife;

(F) Social Worker; or

(G) Registered Nurse;

(b) The Maternity Case Manager must be a Division of Medical

Assistance Programs (DMAP) enrolled provider or deliver services

under an appropriate DMAP enrolled provider. See DMAP General

Rules 410-120-1260 for provider enrollment qualifications;

(c) All of the above must have a minimum of two years of related and

relevant work experience;

(d) Other paraprofessionals may provide specific services with the

exclusion of the Initial Assessment (G9001) while working under the

supervision of one of the practitioners listed in (6)(a)(A-G) of this rule;

(e) The Maternity Case Manager must sign off on all services

delivered by a paraprofessional;

(f) Specific services not within the recognized scope of practice of the

provider of MCM services must be referred to an appropriate

discipline.

(7) Nutritional counselor qualifications -- Nutritional counselors must

be:

(a) A licensed dietician (LD) licensed by the Oregon Board of

Examiners of Licensed Dieticians; and

(b) A registered dietician (RD) credentialed by the Commission on

Dietetic Registration of the American Dietetic Association (ADA).

(8) Documentation Requirements:

(a) Documentation is required for all MCM services in accordance

with DMAP General Rules 410-120-1360; and

(b) A correctly completed DMAP form 2470, 2471, 2472 and 2473 or

their equivalents meet minimum documentation requirements for

MCM services.

(9) G9001 -- Initial Assessment must be performed by a licensed

Maternity Case Manager as defined under (6)(a)(A-G) above:

(a) Services include:

(A) Client assessment as outlined in the "Definitions" section of this

rule;

(B) Development of a CSP which addresses identified needs;

(C) Making and assisting with referrals as needed to:

(i) A prenatal care provider;

(ii) A dental health provider;

(D) Forwarding the initial assessment and the CSP to the prenatal

care provider;

(E) Communicating pertinent information to the prenatal care provider

and others participating in the client's medical and social care;

(b) Data sources relied upon may include:

(A) Initial assessment;

(B) Client interviews;

(C) Available records;

(D) Contacts with collateral providers;

(E) Other professionals; and

(F) Other parties on behalf of the client;

(c) The client's record must reflect the date and to whom the initial

assessment was sent;

(d) The Initial Assessment (G9001) is billable once per pregnancy per

provider and must be performed before providing any other MCM

services. Only a Home/Environmental Assessment (G9006) and a

Case Management Visit (G9012) may be performed and billed on the

same day as an Initial Assessment.

(10) G9002 -- Case Management (Full Service) -- Includes:

(a) Face-to-face client contacts;

(b) Implementation and monitoring of a CSP:

(A) The client's records must include a CSP and written updates to

the plan;

(B) The CSP includes determining the client's strengths and needs,

setting specific goals and utilizing appropriate resources in a

cooperative effort between the client and the Maternity Case

Manager;

(c) Care coordination as follows:

(A) Contact with Department of Human Services (DHS) case worker,

if assigned;

(B) Maintain contact with prenatal care provider to ensure service

delivery, share information, and assist with coordination;

(C) Contact with other community resources/agencies to address

needs;

(d) Linkage to client services indicated in the CSP:

(A) Make linkages, provide information and assist the client in selfreferral;

(B) Provide linkage to labor and delivery services;

(C) Provide linkage to family planning services as needed;

(e) Ongoing nutritional evaluation with basic counseling and referrals to

nutritional counseling, as indicated;

(f) Utilization and documentation of the “5 A’s” brief intervention

protocol for addressing tobacco use (US Public Health Service

Clinical Practice Guideline for Treating Tobacco Use and

Dependence, 2008). Routinely:

(A) Ask all clients about smoking status;

(B) Advise all smoking clients to quit;

(C) Assess for readiness to try to quit;

(D) Assist all those wanting to quit by referring them to the Quitline

and/or other appropriate tobacco cessation counseling and provide

motivational information for those not ready to quit;

(E) Arrange follow-up for interventions;

(g) Provide training and education on all mandatory topics - Refer to

Table 130-0595-2;

(h) Client advocacy as necessary to facilitate access to benefits or

services;

(i) Assist client in achieving the goals in the CSP;

(j) G9002 is billable after the delivery when more than three months

of service were provided. Services must be initiated during the

prenatal period and carried through the date of delivery;

(k) G9002 is billable once per pregnancy.

(11) G9009 -- Case Management (Partial Service):

(a) Can be billed when the CSP has been developed and MCM

services were initiated during the prenatal period and partially

completed;

(b) Provided MCM services to the client for three months or less.

(12) G9005 -- High Risk Case Management (Full Service):

(a) Enhanced level of services which are more intensive and are

provided in addition to G9002;

(b) Provided High Risk Case Management services for the client for

more than three months after the client was identified as high risk;

AND

(c) Provided at least eight Case Management Visits;

(d) G9005 is billable after the delivery and only once per pregnancy;

(e) G9005 can be billed in addition to G9002.

(13) G9010 -- High Risk Case Management (Partial Service):

(a) Are the same enhanced level of services provided in G9005 but

the client became high risk during the latter part of the pregnancy or

intensive high risk MCM services were initiated and partially

completed but not carried through to the date of delivery;

(b ) Provided high risk case management services for the client for

three months or less after the client has been identified as high risk;

OR

(c) Provided less than eight Case Management Visits;

(d) G9010 is billable after the delivery and once per pregnancy;

(e) G9010 can be billed in addition to G9002 or G9009.

(14) S9470 -- Nutritional Counseling:

(a) Is available for clients who have at least one of the following

conditions:

(A) Chronic disease such as diabetes or renal disease;

(B) Hematocrit (Hct) less than 34 or hemoglobin (Hb) less than 11

during the first trimester, or Hct less than 32 or Hb less than 10 during

the second or third trimester;

(C) Pre-gravida weight under 100 pounds or over 200 pounds;

(D) Pregnancy weight gain outside the appropriate Women, Infants

and Children (WIC) guidelines;

(E) Eating disorder;

(F) Gestational diabetes;

(G) Hyperemesis;

(H) Pregnancy induced hypertension (pre-eclampsia); or

(I) Other identified conditions;

(b) Documentation must include all of the following:

(A) Nutritional assessment;

(B) Nutritional care plan;

(C) Regular client follow-up;

(c) Can be billed in addition to other MCM services;

(d) S9470 is billable only once per pregnancy.

(15) G9006 -- Home/Environmental Assessment:

(a) Includes an assessment of the health and safety of the client's

living conditions with training and education of all topics as indicated

in Table 130-0595-1;

(b) G9006 may be billed only once per pregnancy, except an

additional Home/Environmental Assessments may be billed with

documentation of problems which necessitate follow-up assessments

or when a client moves. Documentation must be submitted with the

claim to support the additional Home/Environment Assessment.

(16) G9011 -- Telephone Case Management Visit:

(a) A non-face-to-face encounter between a Maternity Case Manager

and the client, meeting all requirements of a Case Management Visit

(G9012) and when a face-to-face Case Management Visit is not

possible or practical;

(b) G9011 is billable in lieu of a Case Management Visit and counted

towards the total number of Case Management Visits (see G9012 for

limitations).

(17) G9012 – Case Management Visit:

(a) Each Case Management Visit must include:

(A) An evaluation and/or revision of objectives and activities

addressed in the CSP: and

(B) At least two training and education topics listed in Table 130-

0595-2;

(b) Four Case Management Visits (G9012) may be billed per

pregnancy. Telephone Case Management Visits (G9011) are

included in this limitation;

(c) Six additional Case Management Visits may be billed if the client

is identified as high risk;

(A) These additional visits may not be billed until after delivery;

(B) These additional six visits may only be submitted with or after

High Risk Full (G9005) or High Risk Partial (G9010) Case

Management has been billed. Telephone Case Management Visits

(G9011) are included in this limitation;

(d) Maternity Case Management Visits (G9012) may be provided in

the client's home or other site due to documented extenuating

circumstances.

Table 130-0595-1

Table 130-0595-2

Stat. Auth.: ORS 409.050 and 414.065

Stats. Implemented: ORS 414.065

7-1-09

Table 130-0595-1 Environmental Assessment

Housing Characteristics

Location of home and proximity to exposures

General assessment and condition of home as shelter

Number of bedrooms and number of persons

Heating and cooling

Ventilation and windows

Locking entrance

Phone service

Running/potable water

Access to bathroom

Sanitation/sewage and garbage

General Safety

Guns/weapons: locked and unloaded

Lighting adequate for safety

Fall/Trip hazards

Temperatures of hot tubs and hot water tanks

Non-slip shower and bath surfaces

Food Safety

Food preparation facilities

Refrigeration

Cleanable surfaces

Food storage facilities

Health adequacy: safety and sanitation

Toxins/Teratogens

Pesticides

Lead exposure: peeling paint, lead pipes and lead dust

Household cleaners

Indoor Air

Tobacco smoke – second- and third-hand

Wood/Pellet stoves

Mold and mildew

Carbon monoxide risk

Chemical use: in or near home

Radon risk

Asbestos

Pollutants: air fresheners, candles, plug-ins and incense

Fire Prevention

Fire hazards: smoking, candles and flammable item storage

Electrical outlets

Emergency Planning

Smoke alarms: installed and working

Adequate exits: all locations and free of obstacles

Emergency preparedness: escape plan; emergency numbers posted; adequate

food, water and supplies; alternate heating, lighting and cooking capability

Transportation

Occupations & Hobbies

Employment, such as: nail salons, painters, remodelers, home repair,

radiator repair, dry cleaning, gardener, pesticide applicator, farm/orchard

worker, landscape worker

Hobbies, such as: making and using fishing weights or bullets; shooting or

cleaning at indoor shooting ranges

Miscellaneous

Pets: presence or care of dogs, cats, birds, reptiles (lizards & snakes) and

turtles

Cleaning of cat litter box and other pet cages

Administering flea or tick treatments to pets

Pests: presence or management of mice, rats, insects, bedbugs, etc.

Table 130-0595-2 MCM Training and Education Topics

MANDATORY TOPICS

Alcohol, tobacco and other drug exposure

Maternal oral health

Breastfeeding promotion

Perinatal mood disorders

Prematurity and pre-term birth risks

Maternal/Fetal HIV (Human Immunodeficiency Virus) and Hepatitis B

transmission

Nutrition, healthy weight and physical activity

Intimate Partner Violence (IPV)

NON-MANDATORY TOPICS

Pregnancy and Childbirth

Common discomforts and interventions

Labor and birth process

Coping strategies

Relationship changes

Stress reduction

Pregnancy danger signs and symptoms

Fetal growth and development

Safety in automobiles: proper use of seat belts and infant car seats

Other emergencies

Health Status

Medications

Digestive tract changes

Food availability

Food selection and preparation

Mercury consumption from eating fish

Other existing health conditions during pregnancy

Environmental Health

Housing

Safety and sanitation

Toxins/Teratogens

Occupational exposures

Drinking water

410-130-0595 Page 14

Non-fluoridated water community

Home cleaning supplies

Tobacco smoke exposure

Asthma triggers

Lead exposure and screening

Parenting

Infant care

Early childhood caries prevention

Nutrition, feeding and infant growth

Infant sleep patterns and location

SIDS (Sudden Infant Death Syndrome) and “Back to Sleep”

Infant developmental milestones

Immunizations and well child care

Infant/Parent interaction

Bonding and attachment

Infant communication patterns and cues

Parental frustration and sleep deprivation

Child nurturing, protection and safety

Other Topics

Individual and family emergency preparedness

Family planning

Sexually transmitted diseases

Inter-conception and pre-conception health

Community resources

Obtaining accurate health information