Sterilization: Tubal Ligation or Vasectomy Coverage
Security Health Plan follows ForwardHealth guidelines for coverage of sterilization procedures such as tubal ligation or vasectomies. Security Health Plan does not require prior authorization when completed with an affiliated provider.
A sterilization is any surgical procedure performed with the primary purpose of rendering an individual permanently incapable of reproducing. The procedure may be performed in an "open" or laparoscopic manner. This does not include procedures that, while they may result in sterility, have a different purpose such as surgical removal of a cancerous uterus or cancerous testicles.
Federal and state regulations require all of the following:
- The member is not an institutionalized individual.
- The member is at least 21 years old on the date the informed written consent is obtained.
- The member gives voluntary informed written consent for sterilization.
- The member is not a mentally incompetent individual. A "mentally incompetent" individual is defined as a person who is declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purposes, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.
- At least 30 days, excluding the consent and surgery dates, but not more than 180 days, must pass between the date of written consent and the sterilization date, except in the case of premature delivery or emergency abdominal surgery if:
- In the case of premature delivery, the sterilization is performed at the time of premature delivery and written informed consent was given at least 30 days before the expected date of delivery and at least 72 hours before the premature delivery. The 30 days excludes the consent and surgery dates.
- The sterilization is performed during emergency abdominal surgery and at least 72 hours have passed since the member gave written informed consent for sterilization.
Reimbursement for sterilization procedures is dependent on providers fulfilling all federal and state requirements and satisfactory completion of the Wisconsin Medicaid Sterilization Informed Consent form. Security Health Plan does not accept other states’ sterilization consent forms. Providers' failure to comply with any of the sterilization requirements results in denial of the sterilization claims. The completed form should accompany the claim and can be submitted via mail, email or fax:
Security Health Plan
Attn: Claims Department
P.O. Box 8000
Marshfield, WI 54449-8000
Attn: Claims Department at fax number 715-221-9500
Corrections to the forms are allowed, however providers should not white out any previously completed information. Instead, providers should strike-through the incorrect information and add the corrected information. The provider must initial and date next to the correction; if it is a member field then the member must initial and date next to the change.
For a direct link to the Wisconsin Medicaid Sterilization Informed Consent form and for detailed information, see ForwardHealth Topic #1584. See the Hospital, Outpatient Handbook at https://www.forwardhealth.wi.gov/WIPortal/
- Click on Online Handbooks
- Choose the I Accept radio button and Submit Agreement
- Under Choose a user type, select Provider
- Under Choose a program, select BadgerCare Plus and Medicaid
- Under Choose a service area, select Hospital, Outpatient
- Select Covered and Noncovered Services
- Select Surgery Services
- Select Sterilizations