When does the episode start, and how long does it last?
Live birth identified through retrospective review of claims
Health plan / Payer notification during prenatal time period
Episode Length Episode “look-back”
270 days prior to delivery (so long as the woman was pregnant in this time period)
First visit when pregnancy is confirmed
60 days postpartum for mom (most common) or other time period
30 days postpartum for baby (if baby is included) or other time period
How do payers and providers know which patient is being cared for under an episode-based payment?
Include all patients
High-risk pregnancies (which can be defined in many ways and negotiable, and identified after-the-fact for retrospective episodes).
Women who did not receive care from delivering provider during the prenatal time period.
Women whose pregnancy was not confirmed until a pre-negotiated week of pregnancy (this includes women who did not seek services at the start of their pregnancy).
What services are included? Do those services cover care for the baby?
All services inclusive of pregnancy or a smaller subset
If baby is included in episode – consider whether NICU costs will be included, if they occur.