Abortion, Sterilization and Hysterectomy (ASH) Forms FAQ

Q1. Where can I find Instructions for completing these ASH forms?

Q2. If a claim is denied payment because of an issue with the form, can the form be corrected and resubmitted?

  • A2. Yes, the form may be corrected and resubmitted to the MCO for payment of the claim.

Q3. I want to correct something on the form. Can I use correction fluid (white-out)?

  • A3. No. As with any medical documentation, correction fluid is not permitted. To make a correction, strikethrough the original text with a line, write the corrected text nearby, and initial and date the correction.

Q4. Does the signature need to exactly match the name?

  • A4. No. The signature should be similar but does not require an exact match. For example, if the name on the medical record is Ashley Ann Smith, a signature that resembles A Smith is acceptable. Similarly, if the signature resembles an A and S and the rest is not discernable, but the signature is consistent with all other member signatures in the claim, this is acceptable.

Sterilization Consent Form FAQ

Q5. Can I use an “expired” form?

  • A5. Yes. According to CMS, “The sterilization consent form is codified in regulation at 42 CFR §441.258 and §441.259. The form required by regulation must be used regardless of whether there is a current OMB date. Because the form is codified in regulation it never expires. The expiration date now on the sterilization form will continue to be renewed with new dates but for Medicaid purposes the form does not require an expiration date to be valid. This is the only form that can be used, and it may not be altered in any way. The lack of a current form is not a valid reason to deny a claim providing the form has not been altered and is compliant with regulations. A claim should only be denied when the form is not properly completed and signed in accordance 42 CFR §441.258 and §441.259. States wishing to collect additional information not requested on the form may do so on a separate document, but the form may not be altered. If the form is altered, it becomes invalid.”

Q6. Does a correction result in a new 30-day waiting period?

  • A6. No, it does not.

Q7. Does every instance of “type of operation” need to match?

  • A7. No. The type of operation may be described in multiple ways on the same form. For example, the provider may use medical terminology while the recipient uses plain language.

Q8. Do the dates need to be in a specific format?

  • A8. No, though the current Spanish form indicates mes, dia, ano, (mmddyy), the previous version indicated dia/mes/ano (ddmmyy) for the recipient fields. As both current and expired forms are accepted (Q1), any format for date is acceptable.

Q9. Does a sterilization consent form need to be completed if the person is already sterile?

  • A9. No. Informed consent for sterilization is not required if the member has been previously sterilized as the result of a prior surgery, menopause, prior tubal ligation, pituitary or ovarian dysfunction, pelvic inflammatory disease, endometriosis, or congenital sterility. 

Q10. Do I need to cross out the Interpreter’s Statement or write N/A when an interpreter is not used?

  • A10. No, the interpreter’s statement does not require any mark or acknowledgement EXCEPT when an interpreter is utilized.

Q11. The form refers to “Premature delivery,” is this referring to the clinical definition of prematurity?

  • A11. No. Premature delivery (for the sake of this form) refers to any date prior to estimated due date, not the clinical definition of prematurity. For example, if a patient’s due date was September 30th and the form was signed August 30th, but she delivered September 28th, you would be eligible to check off paragraph #2 as this was prior the patient’s due date.