Provider Information

Prior Authorization Request Services and Forms

Hysterectemy

The federal regulation for hysterectomy requires that the recipient has been informed that the hysterectomy will render the individual permanently incapable of reproducing. The recipient must sign a statement acknowledging receipt of infertility information prior to surgery. Most hospital operative permits do not meet the federal requirements for hysterectomy information. The Acknowledgment of Information for Hysterectomy Form meets the requirements.

If the woman was sterile prior to the hysterectomy, you must have the recipient sign the Acknowledgment of Information for Hysterectomy Form. Alternately, the physician may write a statement that the recipient was sterile prior to the hysterectomy and the reason for the sterility. The statement must be signed and dated by the physician and the statement must be attached to the claim.

When a recipient requires a hysterectomy due to a life threatening emergency, and the physician determines that prior acknowledgment is not possible, the physician must certify in writing that the hysterectomy was performed under a life-threatening emergency in which he or she determined prior acknowledgment was not possible. The physician must also include a description of the nature of the emergency. This statement, signed and dated by the physician, must be attached to the claim.

Note: Do not use the Sterilization Consent Form for a hysterectomy.

The Medical Assistance Program does not reimburse for the following:

1. Hysterectomy performed solely for the purpose of rendering an individual permanently incapable of reproducing.
   
   
2. Sterilization of a mentally incompetent individual.
   
   
3. Sterilization of an institutionalized individual.
   
   
4. Sterilization of an individual who has not reached his or her 21st birthday when the sterilization consent form is signed.
   
   
5. Sterilization or hysterectomy when the consent form is not completed, is not accurate or is not legible.
   
   
6. When the consent form or acknowledgment of information was signed more than 180 days prior to surgery.

Acknowledgement of Information for Hysterectomy

• Acknowledgement of Information for Hysterectomy Form

Mail your completed form to:

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone: (605) 773-3495
Fax: (605) 773-5246