Common Errors on Consent Forms

Incorrect Hysterectomy Consent Form - Please refer to the November 2013 Medicaid Bulletin (http://www.ncdhhs.gov/dma/bulletin/1113bulletin.htm) article HYSTERECTOMY STATEMENT FORM REQUIREMENTS. (Providers will begin receiving denials for using the incorrect form on November 1, 2013 for Hysterectomy Statement Forms signed on or after August 1, 2013. The old form will be denied as not correctable after that date. If corrections are needed to the new form, providers should follow the instructions in Section 5.3 of the Hysterectomy Policy, which can be found at www.ncdhhs.gov/dma/mp/1E1.pdf.)

Missing NPI on Hysterectomy Consent Form - Providers must add their National Provider Identifier (NPI) across from the RID (Recipient Identification Number - previously known as the MID or Medicaid Identification Number) for proper Hysterectomy Statement Form and claim matching. Hysterectomy Statement Forms filed without an NPI cannot be matched to the correct claim and will therefore be denied.

Incorrect Sterilization Consent Form - Please refer to the November 2013 Medicaid Bulletin (http://www.ncdhhs.gov/dma/bulletin/1113bulletin.htm) article STERILIZATION CONSENT FORM REQUIREMENTS. The Centers for Medicare & Medicaid Services (CMS) has revised the Sterilization Consent Form. Providers must use the consent form document located in the policy. Consents dated October 1, 2013 and thereafter must be documented using the Sterilization Consent Form located in the policy. Consents signed on or after October 1, 2013 using the old form will be denied with an EOB that states “The consent form submitted is invalid. It is not the federally mandated form. Refer to DMA Clinical Coverage Policy 1E-3. This is not correctable.”

White-Out or Erasure When Correcting Consent Form - If a provider receives a denial of the consent form from DMA’s fiscal agent because an error was located in an area that can be changed, providers must strikethrough the error once on the original consent, make the correction, and send a copy to the fiscal agent. The use of white out or erasures are prohibited.

Not using full name of Physician scheduled to perform the surgery - Per the State Policy: The full name of the physician scheduled to do the surgery must be on the form. Abbreviations, initials, or “doctor on call” are unacceptable. May use “Physician on call for Any Provider OB/GYN clinic.”

Missing NPI on Sterilization Consent Form - National Provider Identifier (NPI) is now required on each Sterilization Consent form. This area is to be completed by the billing provider (surgeon) of the sterilization procedure. Other providers can bill using the consent form on file from the billing provider (surgeon). When the NPI on the claim does not match the NPI on the consent, the claim pends in order to determine if ancillary service is appropriate for the consent procedure.

Illegible Consent Form Copies - In order to process the consent, all fields must be legible.