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