Sterilization Consent Forms and Hysterectomy Statement Reminders

1. N.C. Division of Medical Assistance (DMA) Clinical Coverage Policies (CCP) and Medicaid Bulletin guidelines and regulations are not being followed. The Sterilization Procedures policy (1E-3) and Hysterectomy policy (1E-1) are located on the DMA Clinical Policy web page.

2. All signatures on both Sterilization Consent Forms and Hysterectomy Statements must be legible. Signatures that are illegible should have a printed version of the person’s name above or below the signature. If there is any question of legibility of a signature, ensure there is a printed name on the consent form, prior to submitting it to CSC for review.

3. It is the responsibility of the surgeon to send Sterilization Consent Forms and Hysterectomy Statements to CSC. Hospitals, Anesthesiologists, Pathology Services, and other ancillary providers should never send Sterilization Consent Forms and Hysterectomy Statements to CSC. The National Provider Identifier (NPI) of the rendering provider (surgeon) shall be the only acceptable NPI for Sterilization Consent Forms and Hysterectomy Statements.

4. Rendering providers (surgeons) should submit Sterilization Consent Forms and Hysterectomy Statements within 30 days of the procedure for review and approval.

5. Sterilization Consent Forms and Hysterectomy Statements should not be submitted electronically with the claim at this time. All Sterilization Consent Forms and Hysterectomy Statements shall be mailed to:

CSC

P.O. Box 30968

Raleigh, NC 27622

Important: In accordance with the Hysterectomy policy (1E-1), providers must place the entire Hysterectomy Statement Form on their letterhead so that all three statements are included on the form when submitting a statement for hysterectomies. A title of “Hysterectomy Statement” must appear above the form area before the actual statement information begins.