Pregnancy Incentive Reimbursement Form
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1Pregnancy Incentive Reimbursement Form
Date:
Member Demographics
Patient’s name:
EDC :
Medicaid ID #:
Alternate Contact Information:
Address:
Cell Phone:
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-
Home Phone:
-
-
Work Phone:
-
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❑ US
❑ Urine Test
❑ Blood test
❑
Pregnancy Confirmed by (check applicable box):
other_____________
Date of Test:_______________________
Anticipated Delivery(check applicable box):
❑ NSVD
❑ Cesarean Delivery
Referring Provider
❑ OB
❑Family Practitioner
❑ Perinatologist
Type of Provider (check applicable box):
Practice Name:
Tax Identification #:
Referring Provider / Practice Name :
Phone:
-
-
Fax:
-
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Address:
City/State:
General Instructions
This form should only be submitted for incentive reimbursement requests. A copy of the actual Georgia
Families Pregnancy Notification Form must accompany each submission.
Member must be eligible for Peach State Health Plan benefit at the time the form is submitted for provider to be
eligible for incentive reimbursement.
th
Incentive payment will be mailed to participant on the 15
day of the month following submission.
Incentive Program Incentive Reimbursement Type (check applicable box)
❑Notification of Pregnancy Referral (payable to MD office staff, only)
All submissions should be emailed to:
or fax to: 1-866-532-8835
ATTN: Pregnancy Incentive Program Reimbursement
o
Note: Doctor office staff should continue to fax the Georgia Families Pregnancy Notification forms to our Case
Management
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Department at 1-866-681-5125. A copy of this form can be found Incentive will only be paid out
o
upon verification that the form has been submitted.
A copy of the Georgia Families Pregnancy Notification form must be attached to the Pregnancy Incentive Reimbursement form
in order for the incentive to be paid.
❑17P Program Referral (payable to the physician, only)
All submissions should be emailed to:
or fax to: 1 -866-532-8835
ATTN: Pregnancy Incentive Reimbursement Unit
A copy of Peach State Health Plan prior authorization form for 17P treatment must be attached to the Pregnancy Incentive
Reimbursement Form in order for incentive to be paid.
17P Program Incentive
Georgia Families Notification of Pregnancy form
Must meet both of the following (please check):
Check the applicable box:
❑ Member Gestational Age between 16 – 20 weeks
nd
❑ $25 Visa gift card per form submitted during the 1st & 2
month of
❑ Member with history of Spontaneous Preterm Delivery
pregnancy
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❑ $20 Visa gift card per form submitted during the 3rd & 4
month of
pregnancy
Physician Name ( please print):
❑ $15 Visa gift card per form submitted during the 5th & 6th month of
_________________________________________
pregnancy
Physician Signature:
Physician Office Staff Name ( please print):
__________________________________________________
______________________________
( must be signed by the treating physician)
Physician Office Signature:
___________________________________________
Note: This signature must match signature on Georgia 17P referral form.
Note: Signature must match signature on pregnancy notification form. The
maximum annual incentive payout is $600.00 per staff member.
Do not write below this line: For PSHP Medical Management Department use only
❑ Verified NOP’s received date by PSHP
❑ Gift Card Serial #
❑ Reconciliation Log updated
❑ Date Mailed : __________
Corporate
________________
❑Verified EDC date
❑ Copy of NOP
❑ Check #
CM#__________
attached
_______________________
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