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Prenatal Care Provided by Primary Care Physicians (CPB 0047, reviewed 2026-03-10)
Effective date
Oct 31, 1995
Identified
Aug 13, 2026
Summary
Aetna has clarified billing requirements for primary care physicians providing prenatal care only. PCPs must use CPT 59425 (4-6 visits) or 59426 (7+ visits) for antepartum services, coordinate genetic testing through Aetna's Beginning Right Maternity Program, and refer patients to a participating obstetrician by week 28 for co-management and delivery. This policy requires immediate workflow updates to ensure compliance with billing codes, referral timelines, and enrollment requirements.
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What to do
Action · 9 steps
01IMMEDIATE ACTIONS REQUIRED.
02Billing team must update billing software to enforce use of CPT 59425 (4-6 prenatal visits) or CPT 59426 (7+ prenatal visits) ONLY for primary care physicians providing antepartum care; do not use OB global package codes (59400-59410, 59510-59515).
03Update encounter forms and clinical templates to require PCP documentation of: patient choice of PCP vs. obstetrician, enrollment status in Aetna Beginning Right Maternity Program, and fetal aneuploidy screening consent form completion.
04Implement system flag: At week 28 visit, system must alert billing/clinical staff to verify referral to participating obstetrician has occurred and complete prenatal records have been transferred.
05Claims without evidence of week 28 referral may be denied.
06Front desk/scheduling must confirm all referred obstetrician is 'participating' with Aetna before referral.
07Before billing any genetic testing, ultrasound (76801-76817), or fetal non-stress testing (59025), verify ALL cases are coordinated through Aetna Beginning Right Maternity Program enrollment.
08Providers must present fetal aneuploidy screening consent form in first trimester and document accept/decline.
09Immediately enroll all qualifying pregnant members in Beginning Right Maternity Program before first prenatal billing.
If missed: Failure to comply will result in claim denials and potential contract violations with Aetna.
Codes mentioned
5902559425594267680176802768037680476805768067680776808768097681076811768127681376814768157681676817768188210582106882718827288273882748827588291
Original notice
Prenatal Care Provided by Primary Care Physicians (CPB 0047, reviewed 2026-03-10)
aetna.com · Always check the source before changing claims.
Related changes
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Related policy hubs
Aetna policiesFamily MedicineGeneral PracticeOB-GYNCode 59025Code 59425Code 59426Code 76801Code 76802Code 76803Code 76804Code 76805Code 76806Code 76807Code 76808Code 76809Code 76810Code 76811Code 76812Code 76813Code 76814Code 76815Code 76816Code 76817Code 76818Code 82105Code 82106Code 88271Code 88272Code 88273Code 88274Code 88275Code 88291