410-130-0580 Hysterectomies and Sterilization (1) Refer to OAR 410-130-0200 Prior Authorization, Table 130-0200-1 and 410-130-0220 Not Covered/Bundled Services, Table 130-0220-1. (2) Hysterectomies performed for the sole purpose of sterilization are not covered. (3) All hysterectomies, except radical hysterectomies, require prior authorization (PA). (4) A properly completed Hysterectomy Consent form (DMAP 741) or a statement signed by the performing physician, depending upon the following circumstances, is required for all hysterectomies: (a) When a woman is capable of bearing children: (A) Prior to the surgery, the person securing authorization to perform the hysterectomy must inform the woman and her representative, if any, orally and in writing, that the hysterectomy will render her permanently incapable of reproducing; (B) The woman or her representative, if any, must sign the consent form to acknowledge she received that information. (b) When a woman is sterile prior to the hysterectomy, the physician who performs the hysterectomy must certify in writing that the woman was already sterile prior to the hysterectomy and state the cause of the sterility; (c) When there is a life-threatening emergency situation that requires a hysterectomy in which the physician determines that prior acknowledgment is not possible, the physician performing the hysterectomy must certify in writing that the hysterectomy was performed under a life-threatening emergency situation in which he or she determined prior acknowledgment was not possible and describe the nature of the emergency. (5) In cases of retroactive eligibility: The physician who performs the hysterectomy must certify in writing one of the following: (a) The woman was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; (b) The woman was previously sterile and states the cause of the sterility; (c) The hysterectomy was performed because of a life-threatening emergency situation in which prior acknowledgment was not possible and describes the nature of the emergency. (6) Do not use the Consent to Sterilization form (DMAP 742A or B) for hysterectomies. (7) Submit a copy of the Hysterectomy consent form with the claim. (8) Sterilization Male & Female: A copy of a properly completed Consent to Sterilization form (DMAP 742 A or B), the consent form in the federal brochure DHHS Publication No. (05) 79-50062 (Male), DHHS Publication No. (05) 79-50061 (Female) or another federally approved form must be submitted to the Division for all sterilizations. The original consent form must be retained in the clinical records. Prior authorization is not required. (9) Voluntary Sterilization: (a) Consent for sterilization must be an informed choice. The consent is not valid if signed when the client is: (A) In labor; (B) Seeking or obtaining an abortion; or (C) Under the influence of alcohol or drugs. (b) Ages 15 years or older who are mentally competent to give informed consent: (A) At least 30 days, but not more than 180 days, must have passed between the date of the informed written consent (date of signature) and the date of the sterilization except: (i) In the case of premature delivery by vaginal or cesarean section the consent form must have been signed at least 72 hours before the sterilization is performed and more than 30 days before the expected date of confinement; (ii) In cases of emergency abdominal surgery (other than cesarean section), the consent form must have been signed at least 72 hours before the sterilization was performed. (B) The client must sign and date the consent form before it is signed and dated by the person obtaining the consent. The date of signature must meet the above criteria. The person obtaining the consent must sign the consent form anytime after the client has signed but before the sterilization is performed. If an interpreter is provided to assist the individual being sterilized, the interpreter must also sign the consent form on the same date as the client; (C) The client must be legally competent to give informed consent. The physician performing the procedure, and the person obtaining the consent, if other than the physician, must review with the client the detailed information appearing on the Consent to Sterilization form regarding effects and permanence of the procedure, alternative birth control methods, and explain that withdrawal of consent at any time prior to the surgery will not result in any loss of other program benefits. (10) Involuntary Sterilization — Clients who lack the ability to give informed consent and are 18 years of age or older: (a) Only the Circuit Court of the county in which the client resides can determine that the client is unable to give informed consent; (b) The Circuit Court must determine that the client requires sterilization; (c) When the court orders sterilization, it issues a Sterilization Order. The order must be attached to the billing invoice. No waiting period or additional documentation is required. (11) Submit the Consent to Sterilization Form (DMAP 742 A or B) along with the claim. The Consent to Sterilization form must be completed in full: (a) Consent forms submitted to the Division without signatures and/or dates of signature by the client or the person obtaining consent are invalid; (b) The client and the person obtaining consent may not sign or date the consent retroactively; (c) The performing physician must sign the consent form. The date of signature must be either the date the sterilization was performed or a date following the sterilization. [ED. NOTE: Forms referenced are available from the agency.] [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11 DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08 DMAP 27-2007(Temp), f. & cert. ef. 12-20-07 thru 5-15-08 DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07 OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06 OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 HR 6-1994, f. & cert. ef. 2-1-94 HR 23-1992, f. 7-31-92, cert. ef. 8-1-92 HR 43-1991, f. & cert. ef. 10-1-91 HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0840 AFS 48-1989, f. & cert. ef. 8-24-89 Renumbered from 461-014-0030, AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89 AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86 AFS 42-1985, f. & cert. ef. 7-1-85 AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices AFS 79-1981, f. 11-24-81, cert. ef. 12-1-81 AFS 50-1981(Temp), f. & cert. ef. 8-5-81 AFS 11-1979, f. 6-18-79, cert. ef. 7-1-79 AFS 4-1979(Temp), f. & cert. ef. 3-8-79 PWC 868, f. 12-30-77, cert. ef. 2-1-78 PWC 834, f. 3-31-77, cert. ef. 5-1-77 PWC 813, f. & cert. ef. 10-1-76 PWC 803(Temp), f. & cert. ef. 7-1-76