FALLING THROUGH THE CRACKS: Appendix 2
Minnesota Pregnancy Assessment Form (Instructions below)
This pregnancy assessment form is recommended for use with all pregnant women in Minnesota. This form is required for all persons who receive benefits from Minnesota Health Care Programs (MHCP), which include Medical Assistance (MA), General Assistance Medical Care (GAMC), MinnesotaCare, and MHCP patients enrolled in health plans (Prepaid Medical Assistance Program [PMAP], or MinnesotaCare enrollees). The first screening will be done at the first prenatal visit, and the second screening will be done at a prenatal visit around 24–28 weeks.
Identifying information:
1. Label or write in the identifying information. Include patient’s:name,
date of birth, county of residence, address, MHCP ID # or insurance #, phone
#, and patient’s health plan name (if applicable). Include provider’s:name
and/or clinic name, MHCP Provider ID #, and phone #. If using a label, place
a label on each of the three copies of the form.
2. Submit directly to the health plan for persons with PMAP or MinnesotaCare
enrollees. Listed in the manual are the appropriate addresses/fax numbers
for the Minnesota Department of Human Services and the participating health
plans.
Completion of items:
1. Indicate the race/ethnic categories. Ask the patient with which group(s)
she identifies (optional).
2. Complete the EDC using two digits for month, day, and year.
3. Report the number of weeks of gestational age at the first visit and at
the second screening between 24–28 weeks.
4. List the actual dates of the screening visit using two digits for month,
day and year.
Complete items 1–39 by marking an X in the appropriate box.
Other Risks: If you identify other risks, please write them in this
box.
Is this an at risk pregnancy? Check “yes” if you
determine this pregnancy to be at riskregardless of the number or type of
risk factors.
Enhanced services for MHCP enrollees: Please document the services
to be provided to MHCP enrollees to address identified risk factors. Check
the boxes that apply, and list who will provide these services.
Signatures: Please sign and date the appropriate provider box for each
screening.
WIC referral: Pregnant women who are on Medical Assistance and/or who
are working and meet federal income guidelines can receive free nutritious
food and additional nutrition counseling during their pregnancy. Please refer
to WIC (1–800–657–3942).
What to do with the completed form: Retain two copies of the completed form for your patient’s record. Send one copy to the payer (health plan or DHS) for the first screen. Some health plans encourage providers to fax a copy to expedite payment and/or begin case management. After the second screen, send the second copy to the payer. If you are referring this patient to a community health service (CHS) agency, it may be appropriate to send a copy of the form with the referral.
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| Definition for Enhanced Services (See training manual for more complete definitions.) Enhanced Services are a package of prenatal health services for MHCP enrollees who are determined to be at risk by this assessment. At Risk Antepartum Managment: Provider who is primarily responsible for care of patient. Care Coordination: Development, implementation, and ongoing evaluation of plan of care. Prenatal Health Education I: Instruction on general information about pregnancy, warning signs of early labor, and education about other medical conditions. Prenatal Health Education II: Education for patient who requires additional education related to at risk behaviors. Prenatal Nutrition Education: Information and support for appropriate nutritional intake. Postpartum Follow-up Home Visit: Visit planned within the first two weeks postpartum for assessment and education. |
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