Pregnancy Notification - Providers - Texas Children's Health Plan



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	Initial Prenatal Visit Form
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Initial Prenatal Visit Form

Who is eligible to participate?
Providers who are eligible include:

In or out of network physicians delivering obstetrical care for pregnant TCHP members.

How do I submit?
Providers must:

Submit one notification per pregnancy.
Fax process or online submission or faxed initial visit accepted.
Complete required data elements on the OB Initial Visit Form.
Complete the form or first record submission within 14 days of the visit.

The online OB Initial Visit Form should be submitted after the member’s initial prenatal visit. The form will facilitate enrollment of pregnant members into the Texas Children's Health Plan STAR Babies Program and identify high-risk members for case management. Complete the form in its entirety for it to be accepted. Once you notify us, you will receive a flat rate of $40 per initial visit submission with all required elements. TCHP mails payments quarterly. Members must have current TCHP eligibility at the time of payment. Call Provider Relations at 832-828-1008 if you have any questions or call toll-free at 1-800-731-8527.

* Please note, completion of this form is for informational purposes only and is not an authorization of services. For authorization, contact Utilization Management at 832-828-1004, Option 5 or toll free at 1-877-213-5508.

Physician information
Submitting physician’s NPI:
Physician tax ID:
Physician/nurse practitioner name:
Member information
Member's ID number:
Member's name:
Member's birthday (mm/dd/yyyy):
Member's height (inches):
Member's weight (pounds):
Gravidity:
Parity:
Parity term (how many babies carried to term):
Parity preterm (how many babies delivered preterm):
Parity abortions (how many abortions or miscarriages):
Parity living (how many living children):
Expected date of delivery (mm/dd/yyyy):
or Last menstrual period date (mm/dd/yyyy):
Date of last pap smear (mm/dd/yyyy):
History of hypertension?	Yes No
History of diabetes?	Yes No
Weeks gestation on first visit:
Date of first prenatal visit to any doctor for this pregnancy (mm/dd/yyyy):
Is this a high risk pregnancy?	Yes No
Multiple pregnancy?	No Triplets Twins


If you would prefer to print and fax the Initial Prenatal Visit form, please click here and Fax the form to 832-825-8779.