Mom's GEMS Prenatal Program
The National Institutes of Health states, “Having a healthy pregnancy is one of the best ways to promote a healthy birth. Getting early and regular prenatal care improves the chances of a healthy pregnancy.” A healthy mom and baby is the top priority of our Mom’s GEMS Prenatal Program. Mom’s GEMS (Getting Early Maternity Services) Prenatal Program helps to ensure that expecting members get proper prenatal care and education on how to promote a healthy pregnancy and healthy baby. Mom’s GEMS’ will give your patients guidance by helping them with:
- Education on importance of keeping all Ob/Gyn routine visits
- Help coordinating access to specialists, or other doctors
- Case/Care management services – Nurses and Social Workers
- Transportation through LogistiCare
- Nutrition advice
- Breastfeeding guidance
What providers need to do
As part of this program, Horizon NJ Health requires obstetricians or other approved licensed health care providers, including nurse midwives, to complete the Division of Medical Assistance and Health Services’ (DMAHS) uniform Perinatal Risk Assessment (PRA) forms.
Providers will not be reimbursed for prenatal services without a submitted PRA form. Please follow the steps below to submit the PRA forms.
- Complete and submit the Initial Visit PRA form for all patients at the first prenatal visit. Forms should be entered and submitted within three business days. The responses on the Initial Visit PRA forms are used to risk-stratify our members into our GEMS Care Management Program.
- Complete and submit a Follow-up PRA form to update information provided in the Initial Visit PRA form. The Follow-up PRA form should be submitted anytime there is an insurance change, and when any risk factors or other patient information changes.
- New: Complete and submit a Third Trimester PRA form when the patient is 30 to 36 weeks gestation.
All prenatal care providers must be registered with Family Health Initiatives (FHI) in order to access PRA|SPECT. Register online at praspect.org or call 1-856-665-6000. New users must register by calling FHI at 1-856-665-6000 or emailing PRA@FHIWorks.org. PRA forms are submitted by logging into praspect.org.
Tikka Attach
Medicaid PE
ALL FIELDS REQUIRED PLEASE PRINT CLEARLY
Version-3: TF11931 201706 Page 1 of 2
Perinatal History
Y N
Black
White
Asian
Native American
Multi-Racial
Other
Alaskan/Pacific Islander
Race
(Choose one)
English
Spanish
Other
Health Insurance
(Select all that apply)
Medicaid MCO
(Choose one )
Aetna Better Health
Amerigroup
Horizon NJ Health
UnitedHealthcare Community
WellCare
None
Current
Pregnancy
Pregnancy Risk Factors
Entry Into Prenatal Care
SSN Insurance ID/Medicaid #
- -
Date Form Completed
M M D D Y Y
- -
DO NOT PHOTOCOPY BLANK FORMS PLEASE COMPLETE AND FAX TO: 856-662-4321
- -
- -
- -
- -
EDD
M M D D Y Y
Y YD DM M
LMP
M M D D Y Y
M M D D Y Y
1st Visit
Medicaid FFS
Medicaid MCO
Medicare
NJ Family Care
Commercial/Private
Uninsured/Self Pay
Primary Language
(Choose one)
(specify)
Fetal Genetic/Structural Abnorm
na naLow Birth Weight (< 2500gm)
Hyperemesis
Obesity
Gestational Diabetes
PIH/Preeclampsia
Placenta Previa
Cervical Incompetence
Abdominal Surgery
Maternal Fetal Infection
Rh Negative
Oligo/Polyhydramnios
Abnormal Amniocentesis
Abnormal AFP
NYNYNYY N
Prior
Pregnancy
Y N
na naHistory of PROM Urinary Tract Infection
? 2019 Family Health Initiatives 2500 McClellan Ave, Ste 270 Pennsauken, NJ 08109
www.praspect.org
Ethnicity Hispanic Yes
IUGR
Macrosomia
Fetal Reduction
Multiple Gestation Pyelonephritis
STATE OF NEW JERSEY
PERINATAL RISK ASSESSMENT
First Visit Form
1st Visit
Under MCO
Cats or Birds in Home
Alcohol Use
Illicit Drug Use
Unk Unk Unk
First pregnancy? Yes No
-Height (ft-inches)
Pre Pregnancy
Weight (lbs)
Current
Weight (lbs)
/Blood Pressure
Physical Assessment
1st Trimester
2nd Trimester
3rd Trimester
None
Bleeding During Current Pregnancy
Hepatitis A
Hepatitis B
Hepatitis C
Group B Strep
Opioid Replacement Tx
# Live Births Now Living
# Miscarriages < 20 wks
# Previous Live Births
# Induced Terminations
# Ectopic or Molar Pregnancies
# Pregnancies Including Current
Date of last live birth- -
M M D D Y Y
na
na
na na
na
na
na na
na na
na na
na na
Eclampsia
na na
# Preterm Births < 37 wks
# Previous Cesarean Sections
Date of last other pregnancy outcome- -
M M D D Y Y
Current
Pregnancy
Prior
Pregnancy
Current
Pregnancy
Prior
Pregnancy
Infertility Treatment
If No Skip to
Pregnancy Risk Taken by Mother
No Fertility enhancing drugs, artificial insemination or intrauterine insemination Assisted reproductive technology (IVF, GIFT, ZIFT)
Opiate Dependence
Insulin Dependent
If Yes, skip to Physical Assessment
na
PRA ID
Planned Delivery
Site Code
Provider Information
Chart #
Yes No
Name of Father of the Baby
County
Emergency Contact Name
Patient
Information - -
Date of Birth
M M D D Y Y
First NameLast Name
City
- -
Zip Code Primary Phone - -
Street Address
Emergency Contact Phone
Yes NoMarried . . . . . . . . . . . . . . . . . . . .
Father of Baby Involved . . . . .
Preferred Contact Text Call
- -
Y YD DM M
Insurance Effective Date
# Fetal Deaths > 20 wks
# Term Births > 37 wks
FVF
Taken by Father Insemination
16152
16152
SA
MP
LE
DO
N
OT
PH
OT
OC
OP
Y
Current Medical Conditions/Risks
Yes No
Lupus
Cancer
Uterine Abnormalities
Yes No
Abnormal Pap Smear
STD
Yes No
HIV Test Refused
Provider Chart #
Psychosocial Risk Factors
Yes No
Education <12 Years
Disabled Unemployed/Inadequate Income
Husband/Partner is UnemployedHomeless
Unstable Housing
Transportation
Insurance Enrollment Delay
Unaware of Importance of PNCChild Care Issues
Couldn't Find a Health ProviderFinancial
Yes
Access to Preg Test
Inadequate Social Support
Unplanned Pregnancy
Nutritional Concerns
Currently in Foster Care
Eating Disorder
Yes No
Abortion Desired/Unsuccessful
DO NOT PHOTOCOPY BLANK FORMS
Page 2 of 2
PLEASE COMPLETE AND FAX TO: 856-662-4321
Allergies
AIDS
Transportation
Perinatal Depression
Chronic Hypertension
Heart Condition
Cystic Fibrosis
Tuberculosis
Asthma
Depression/Mental Illness
Seizures
Neurological Condition
On
Meds
Phlebitis/DVT
Anemia
Diabetes
Thyroid Disease
Sickle Cell Trait
Sickle Cell Disease
Liver Disease
Renal Disease
Blood Dyscrasia
Domestic Violence
On
Meds
2nd or 3rd Hand Smoke
Home Built Before 1978
Sensitive/Bleeding Gums
Dental Visit w/in the Year
Thalassemia
Unk Unk
Unk Unk
na
na
Yes
Reason for Late Entry to Prenatal Care
Yes No Unk
SSI
Nutritional Consult
Community Based Services*
DCP&P
Substance Abuse Prevention Ed
Tobacco Cessation
Mental Health Assessment
Domestic Violence Assessment
Substance Abuse Assessment
TANF/GA
Emergency Assistance
WIC
Food Stamps
Childbirth Education
Referrals/Education
Diabetes Care Program
Preterm Labor Prevention
Breastfeeding Consult
Dental Referral
Referred Receiving Referral Refused Not
Services Needed Needed
na
* Includes referrals to local Community Health Worker, Community
Home Visiting and other supportive services
Medications/Comments Referred Receiving Referral Refused Not
Services Needed Needed
na
? 2019 Family Health Initiatives 2500 McClellan Ave, Ste 270 Pennsauken, NJ 08109
www.praspect.org
na na
na
Unaware of Pregnancy
Unk
na
Smoking/Tobacco Use
How many cigarettes OR packs did you smoke per day in the three months before pregnancy?
Insulin Dependent
na
na
na
nana
Congenital Abnormalities na
na na
HIV Positive
Patient
History
Patient
History
On
Meds
na
na na
na na
na na
nana
Patient
History
na
PRA ID
na
na
PacksCigarettes
OR
Did either of your parents have a problem with drugs or alcohol
4Ps Plus Yes No
Have you ever drunk beer/wine/liquor
Yes No
*Any None
Does your partner have any problem with drugs or alcohol
Have you ever felt manipulated by your partner
Have you ever felt out of control or helpless
Over the past 2 weeks
Have you felt down, depressed or hopeless
Have you felt little interest or pleasure in doing things
In the month before you knew you were pregnant
How many cigarettes did you smoke
How much beer/wine/liquor did you drink
How much marijuana did you use
If Any is
checked,
continue with
the 4Ps
Follow-Up
Questions
4Ps Plus Follow-up Questions (if *Any above was checked)
In the month before you knew you were pregnant :
About how many days a week did you usually
drink beer / wine / liquor
use any drug such as marijuana, cocaine or heroin
And now, about how many days a week do you usually
drink beer / wine / liquor
use any drug such as marijuana, cocaine or heroin
Refer for Assessment
3-6 Days/Wk
Prevention Education
1-2 Days/WkEvery Day <1 Day/Wk
No Referral Needed
Did Not Drink/Use Drugs
ALL FIELDS REQUIRED
Version-3: TF11931 201706 FVF
Non Smoker
16152
16152
SA
MP
LE
DO
N
OT
PH
OT
OC
OP
Y