Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix F

The Division will make reimbursement only for those hysterectomy procedures, which meet the

criteria established in Subsection 911.3 of this Manual.

A copy of the “Patient’s Acknowledgement of Prior Receipt of Hysterectomy Information”

(DMA-276) is shown on Page I-2 of this Appendix. This form must be signed, either before or

after the hysterectomy, as follows and must be attached to the claim form submitted to the

Division for payment:

A. Section I - Member’s Statement

The member or her representative must sign and date this form in the spaces provided unless the

member was sterile prior to the hysterectomy, or the hysterectomy was an emergency.

B. Section II - Physician’s Statement

The physician must sign and date this form on all hysterectomies performed. If the member was

sterile prior to the hysterectomy, the physician must indicate this condition beside #1 and state the

reason for prior sterility. If the hysterectomy was an emergency, the physician must indicate this

condition beside #2 and attach the discharge summary and operative record.

NOTE: Medicaid funds are unavailable for sterilization, hysterectomies, or abortions performed

without the documentation required by federal regulations (See 42 CFR 441.206 and 441.256).

As such, claims for payment submitted without the required documentation or with incomplete or

inaccurate documentation will be denied. The Division does not accept documentation meant to

satisfy informed consent requirements which has been completed or altered after the service was

performed.