Termination of Pregnancy

First and second trimester terminations of pregnancy require prior authorization and are covered in the following two circumstances:

  1. The member's life is endangered if she were to carry the pregnancy to term.
  2. The pregnancy is the result of an act of rape or incest.

Life threat
When termination of pregnancy is necessary to avert a threat to the member's life, a physician must certify in writing and document in the member's record that the life of the member would be endangered if the pregnancy were allowed to progress to term. The decision as to whether the member's life is endangered is a medical judgment to be made by the member's physician.

This certification must be made on the Pennsylvania Department of Human Services' (DHS) physician certification for an abortion (MA3) (PDF). The form must be completed in accordance with the instructions and must accompany the claims for reimbursement. All claims and certification forms will be retained by Keystone First. If the member is under the age of 18, a recipient statement form (MA368) (PDF) must be completed and submitted.

Rape or incest
When termination of pregnancy is necessary because the member was a victim of an act of rape or incest the following requirements must be met:

  • Using the Pennsylvania Department of Human Services' physician certification for an abortion (MA3) (PDF), the physician must certify in writing that:
    • In  the physician’s professional judgment, the member was too physically or psychologically incapacitated to report the rape or incest to a law enforcement official or child protective services within the required timeframes (within 72 hours of the occurrence of a rape or, in the case of incest, within 72 hours of being advised by a physician that she is pregnant) or:
    • The member certified that she reported the rape or incest to law enforcement authorities or child protective services within the required timeframes.
  • Using the Pennsylvania Department of Human Services' recipient statement form (MA 368 (PDF) or MA 369 (PDF), the physician must obtain the member's written certification that the pregnancy is a result of an act of rape or incest and:
     -The member did not report the crime to law enforcement authorities or child protective services; or
     -The member reported the crime to law enforcement authorities or child protective services.
  • The Pennsylvania DHS' physician certification for an abortion (MA3) (PDF) and the recipient statement form must accompany the claim for reimbursement. The physician certification for an abortion and recipient statement form must be submitted in accordance with the instructions on the certification/form. The claim form, physician certification for an abortion, and recipient statement form will be retained by Keystone First.

Submit claims and forms to:
Keystone First
Family Planning
P.O. Box 7115
London, KY   40742

Providers