Form CMS-10407 Maternity Scenario

Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the

Having a baby (normal delivery)

Scenario tab.

Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory Tests
Prescriptions
Radiology
Vaccines, other preventive
Total

$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540

Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier
(or the tier associated with the lowest level of
cost sharing), for those products that
incorporate tiered provider networks.. No outof-network charges or any other variation in
Sample Care Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
All medications are covered as generic equivalents if available.
If the plan has a wellness program that varies
the deductibles, co-payments, co-insurance,
or coverage for any of the services listed in a
treatment scenario, the plan must complete
the calculations for that treatment scenario
assuming that the patient is participating in
the wellness program. networks.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Medical Condition:

Maternity

Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into
that category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service
under another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs"
section. Examples of cost sharing and benefit features include, but are not limited to:
• Payment of services based on the location such as inpatient, outpatient, or office; and
• Payment of items as prescription drugs vs. medical equipment.
Explanation of Scenario:
Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded.
Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered.
ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service.
ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC.
Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider.
Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab.
Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code.
Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing.
Notes – includes any special notes for an item or service.
CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Totals:
ICD-9
ICD-10
Date of
Diagnosis
Diagnosis
CPT©, HCPCS, or Other Billing Code
Service
Code
Code
07-Jan

$

7,466.39
Allowed
Amount

Provider Type

Category

Description

OTC

Pharmacy Retail

Pharmacy

Prenatal Vitamins (OTC - Bottle of
100) [1 pill daily; 30 pills/month]

$

30.00

Notes

01-Apr

V22.0

Z34.01

80055

OBGYN

Laboratory tests

Obstetric Panel

$

54.24 80055 - Global OB panel code

01-Apr

V22.0

Z34.01

87801 x2

OBGYN

Laboratory tests

Detect agnt mult dna ampli

$

9.45 Gonorrhea / Chlamydia screen

01-Apr

V22.0

Z34.01

88164

OBGYN

Laboratory tests

Cytopath TBS C/V Manual

$

14.74 Pap smear

01-Apr

V22.0

Z34.01

86701

OBGYN

Laboratory tests

HIV-1

$

12.94

01-Apr

V22.0

Z34.01

36415

OBGYN

Laboratory tests

Routine Venipuncture

$

4.13

01-Apr

V72.42

Z32.01
Z34.01

81025

OBGYN

Laboratory tests

Urine Pregnancy Test

$

8.87

01-Apr

V22.0

Z34.01

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

07-Apr

V22.0

Z34.01

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

Totals:
Date of
Service

$
ICD-9
Diagnosis
Code

ICD-10
Diagnosis
Code

07-Apr

CPT©, HCPCS, or Other Billing Code

Provider Type

Category

Description

OTC

Pharmacy Retail

Pharmacy

Prenatal Vitamins (OTC - Bottle of
100) [1 pill daily; 30 pills/month]

7,466.39
Allowed
Amount

$

Notes

30.00

27-May

V22.0

Z34.01

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

24-Jun

V22.0

Z34.01

82105

OBGYN

Laboratory tests

Alpha-fetoprotein serum

$

27.86 Maternal serum quad screen

24-Jun

V22.0

Z34.01

82677

OBGYN

Laboratory tests

Alssay of estriol

$

26.63 Maternal serum quad screen

24-Jun

V22.0

Z34.01

84702

OBGYN

Laboratory tests

Chorionic gonadotropin test

$

21.47 Maternal serum quad screen

24-Jun

V22.0

Z34.01

86336

OBGYN

Laboratory tests

Inhibin A

$

22.50 Maternal serum quad screen

24-Jun

V22.0

Z34.01

83912

OBGYN

Laboratory tests

Genetic examination

$

11.78 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

83891

OBGYN

Laboratory tests

Molecule isolate nucleic

$

7.20 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

83900

OBGYN

Laboratory tests

Molecule nucleic ampli 2 seq

$

31.84 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

83901 x13

OBGYN

Laboratory tests

Molecule nucleic ampli addon

$

129.52 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

83914 x32

OBGYN

Laboratory tests

Mutation ident ola/sbce/aspe

$

50.06 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

83909

OBGYN

Laboratory tests

Nucleic acid high resolute

$

18.98 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

36415

OBGYN

Laboratory tests

Routine Venipuncture

$

4.13 Cystic fibrosis screen

24-Jun

V22.0

Z34.01

Bundled in global OB package - 59400

OBGYN

Routne Obstetric Care

Office/Outpatient Visit Est

OTC

Pharmacy Retail

Pharmacy

Prenatal Vitamins (OTC - Bottle of
100) [1 pill daily; 30 pills/month]
Office/Outpatient Visit Est

06-Jul

Bundled

Bundled
$

30.00

22-Jul

V22.0

Z34.02

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Bundled

22-Jul

V22.0

Z34.00

76805

Radiology

Radiology

19-Aug

V22.0

Z34.02

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

16-Sep

V22.0

Z34.02

82947

OBGYN

Laboratory tests

Assay Glucose Blood Quant

$

6.43

16-Sep

V22.0

Z34.02

85025

OBGYN

Laboratory tests

Complete cbc w/auto diff wbc

$

12.28

OB US >/= 14 WKS SNGL FETUS $

176.11
Bundled

16-Sep

V22.0

Z34.02

82950

OBGYN

Laboratory tests

Glucose Test

$

6.95

16-Sep

V22.0

Z34.02

36415

OBGYN

Laboratory tests

Routine Venipuncture

$

4.13

16-Sep

V22.0

Z34.02

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

30-Sep

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

Totals:
Date of
Service

$
ICD-9
Diagnosis
Code

ICD-10
Diagnosis
Code

04-Oct
14-Oct

V22.0

Z34.03
Z32.2
Z34.03
Z32.2
Z34.03

20-Oct
27-Oct

7,466.39
Allowed
Amount

CPT©, HCPCS, or Other Billing Code

Provider Type

Category

Description

OTC

Pharmacy Retail

Pharmacy

Prenatal Vitamins (OTC - Bottle of
100) [1 pill daily; 30 pills/month]

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

S9442

Alternative Provider

Education

Birthing class

-

S9442

Alternative Provider

Education

Birthing class

-

$

30.00

28-Oct

V22.0

Z34.03

87653

OBGYN

Laboratory tests

Strep B DNA Amp Probe

28-Oct

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

28-Oct

V04.81

Z23

90471

OBGYN

Vaccines, other preventive

Immunization Admin

$

20.04

28-Oct

V04.81

Z23

90656

OBGYN

Vaccines, other preventive

Flu Vaccine N0 Preserv 3 & >

$

15.04

S9442

Alternative Provider

Education

Birthing class

-

S9442

Alternative Provider

Education

Birthing class

-

Z32.2
Z34.03
Z32.2
Z34.03

01-Nov
08-Nov

Notes

$

40.61
Bundled

11-Nov

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

18-Nov

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

25-Nov

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

02-Dec

V22.0

Z34.03

Bundled in global OB package - 59400

OBGYN

Routine Obstetric Care

Office/Outpatient Visit Est

Bundled

09-Dec

650
V27.0
Proc: 73.59

080
Z37.0
Proc:
10E0XZZ

01967

Anesthesiology

Anesthesia

Anesth/analg vag delivery

$

905.62

09-Dec

650
V27.0
Proc: 73.59

080
Z37.0
Z39.01
Proc:
10E0XZZ

**(DRG) 795

Inpatient Facility

Hospital charges (baby)

Normal newborn

$

851.56

09-Dec

V30.00

Z38.00

**(DRG) 775

Inpatient Facility

Hospital charges (mother)

Vaginal delivery w/o complicating
diagnoses

$ 2,714.26

09-Dec

650
V27.0
Proc: 73.59

080
Z37.0
Proc:
10E0XZZ

59400

OBGYN

Routine Obstetric Care

Obstetrical Care

$ 2,084.28

59400 - Global OB package
description/code

09-Dec

650
V27.0

Z34.03

S9443

Inpatient Facility

Education

Lactation class

-

Included in hospital rate**

Totals:
Date of
Service

$
ICD-9
Diagnosis
Code

ICD-10
Diagnosis
Code

CPT©, HCPCS, or Other Billing Code

Provider Type

Category

11-Dec

OTC

Pharmacy Retail

Pharmacy

11-Dec

00591346601

Pharmacy Retail

Pharmacy

11-Dec

00378710401

Pharmacy Retail

Pharmacy

Bundled in global OB package - 59400

OBGYN

Routine obstetric Care

23-Dec

V24.2

Z39.2

Allowed
Amount

Description
Docusate sodium (OTC) [1 pill QD] $
Ibuprofen 800mg (Rx) [1 pill Q8H
PRN; 60 pills]
Oxycodone/APAP 5mg/325mg
(Rx) [1 pill Q6H PRN; 15 pills]
Office/Outpatient Visit Est

7,466.39
Notes

30.00

$

17.52

$

5.21
Bundled

Post partum visit

** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances may occur based on how health plan hospital contracts are structured (e.g.,
case rate, per diems, percentage of billed charges, etc.)

The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group
health plans and health insurance issuers in applying benefits to each item and service.
Provider Type
Anesthesiology
Inpatient Facility
Obstetrics/Gynecology
Pharmacy Retail
Radiology

What providers are covered under this Provider Type and other notes:

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to
the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the
"Scenario" tab and Coverage Example label.
Category
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive

What services are covered under this Category and other notes:
Applies to maternity scenario only; other scenarios would use "Hospital charges"
Applies to maternity scenario only; typically a bundled payment
Applies to maternity scenario only; other scenarios would use "Hospital charges"
Includes blood work
Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not
administered in a hospital, physician's office or other facility. Note, this category also includes
over-the-counter drugs such as prenatal vitamins and other pharmacy items.
Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146