30/05/2025
10.4 Ante-natal registration is approved by HMO at three month of gestation
Dr Adedeji Modupe, a Lagos-based Consultant Obstetrician and Gynaecologist defines pregnancy (gestation) as,
"The maternal condition of having a developing fetus in the body".
The human conception from the fertilisation through the 8th week of pregnancy is called EMBRYO.
From the 8th week until delivery is called FETUS.
In health insurance practice in Nigeria, a pregnant woman is formally due for ante-natal registration by NHIA, and her HMO, at 3-month or 12-13th weeks of pregnancy. What this implies is that a pregnant woman, whose pregnancy is not up to 3-month old, is not due for ante-natal registration by her Health Maintenance Organisation (HMO).
Again, relying on work experience in the past THIRTEEN (13) years; the author of this book experienced many cases of pregnant women whose pregnancies were less than 3-month old, but requested to register for ante-natal care under their health insurance. Such requests were usually declined by their health insurance companies on the ground that their gestations or pregnancies were less than 3-month old and such women were advised to wait until 12th or 13th week of pregnancy to be registered for ANC.
HMOs or health insurance companies usually request hospitals to tell them the last menstrual periods (LMPs) of pregnant women requesting to be registered for ante-natal care. From the LMP of a pregnant woman, the doctor is able to calculate and know how old a woman's pregnancy is. However, the best way to calculate accurately and know how old a woman's pregnancy is, is to request her to do an Obstetric Ultrasound Scan (USS). This scan captures and shows the exact number of weeks and days a woman's pregnancy is.
Once it is confirmed by the Obstetrician or Gynaecologist that a woman's pregnancy is up to 3-month old, the health insurance customer service officer or HMO Officer is expected to contact the woman's HMO and request for an authorisation or approval code for her to start ante-natal care at the hospital, to be paid for by her HMO.
By granting authorisation code for a pregnant female enrollee to start attending ante-natal clinic at a hospital or healthcare provider, it means that the HMO has agreed to pay the hospital for the enrollee's ante-natal bills, or claims as it is called in health insurance practice. The hospital is then required to send the woman's ante-natal claims to the HMO for processing and payment.
An ANC authorisation code covers a pregnant woman's ante-natal care from the period of registration at 3-month of pregnancy to delivery period. At the point of delivery, the HMO Officer of the hospital where the woman is doing ANC is expected to contact her HMO for another authorisation code for delivery (normal delivery or cesarean section as the case may be).
Ante-natal authorisation code also covers what we call 'ROUTINE ANC INVESTIGATIONS" for a pregnant woman.
These routine ANC investigations include: Parked Cell Volume (PCV) to check and know her blood level or volume percentage (vol%) of red blood cells (RBC) in blood, with a view to preventing anaemia in pregnancy, Obstetric Ultrasound (USS), usually done 2 to 3 times before delivery; HIV Screening to know her HIV status (negative or positive), Blood Group, Genotype, Blood Sugar Test (Glucose Test); Venereal Disease Research Laboratory test (VDRL), Urinalysis, Urine M/C/S, Hepatitis B Screening Antigen (HbSAg), Hepatitis C Screening, etc.
Once approved, the HMO is expected to pay the hospital or healthcare provider for ANC registration and routine investigations listed above, by way of payment for ANC package; in line with the agreed tariff between the HMO and hospital where the enrollee is accessing ante-natal care.
Every hospital or maternity clinic that renders ante-natal care has ante-natal clinic days, when pregnant women doing ante-natal do come for ante-natal care.
A pregnant woman who is a health insurance enrollee and who is doing ANC, may also come for treatment in the course of ante-natal and can even be admitted; treated and managed for pregnancy induced hypertension (PIH), malaria, gastritis; gastroenteritis, typhoid fever and other diagnoses but such admission is not covered by her ante-natal authorisation code already issued to the healthcare provider by her HMO. Admission authorisation code is requested by her healthcare provider, with which her admission bill is sent to her HMO after treatment and discharge.
10.5 ANC registration is approved by HMO only in one hospital
In health insurance practice in Nigeria, ante-natal registration is approved for a pregnant woman by her HMO, only in one hospital.
ANC registration is a bundle package that takes care of ante-natal clinic and routine investigations and once a woman is registered by her HMO in one hospital, she is expected to complete her ante-natal care in that hospital where her HMO has paid for her ante-natal care.
These days, a number of HMOs do request to speak to pregnant female enrollees who are about to register for ANC at the healthcare providers under their HMOs. For instance, an HMO call agent, usually, would ask a pregnant female enrollee whether her residence is close to the hospital for easier access, and whether she likes the quality of their service to the extent of doing ANC there. The HMO would also let her know that once ANC is approved for her in her chosen hospital, payment will be made for it to the hospital, and she would not be allowed to go to another hospital to continue her ANC as that would mean that her HMO would have to make another ANC payment to the second hospital.
If a pregnant woman doing ANC in one city or town relocates to another -say for reason of change of job or others- and wishes to continue her ANC in another hospital, the HMO Officer of that hospital is expected to contact her HMO to find out whether they would register her for completion of her ANC and make payment to her hospital. It is the prerogative of the HMO to approve or not. If they approve, the woman would continue her ANC under her HMO care but if they do not approve, she would have to make out-of-pocket cash payment to her new hospital to complete her ANC and her HMO would pay her current hospital for delivery if her insurance policy covers it.
Book title: Practical Working of the Health Insurance System in Niogeria.
Book authored by Osimi, Chukwuka Frank ( Frank Chukwuka Obianke ).
KIndly check Amazon to buy soft copy of book).
WhatsApp: +2349080716061.
Thank you.
