Termination of Pregnancy
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This document governs AmeriHealth Caritas Delaware's coverage and prior authorization requirements for termination of pregnancy services, including coding and billing guidance, as permitted under state law and DMAP funding; it affects providers billing Delaware Medicaid and MCO members for abortion services.
In accordance with House Bill 110 effective 1/1/2025 DMAP will cover termination of pregnancy services as permissible under the law and services are only funded by State resources for both FFS and MCO members, and must be billed through the FFS program.
First and second trimester terminations require prior authorization and are covered if the member's life is endangered or the pregnancy resulted from rape or incest.
List of CPT/HCPCS and HCPCS-like codes (including S0190, S0191, S0199 and multiple 598xx and anesthesia code 01966) are specified for state-funded abortion services and must include modifier SE and diagnosis Z33.2 when submitted to DMAP.
Coverage Criteria for Termination of Pregnancy
Coverage Criteria
AmeriHealth Caritas Delaware will cover termination of pregnancy for first and second trimester procedures when ALL of the following are met:
ALL of the following
- Prior authorization requirement
Prior authorization is required for first and second trimester terminations.
ONE of
- The member's life is endangered if she were to carry the pregnancy to term.
- The pregnancy is the result of an act of rape or incest.
ALL of the following
- Services are funded by State resources and must be billed through the FFS program.
- Providers must contact DMAP Provider Services for historical utilization and remaining benefit before authorization/claim submission.
- Claims submitted to DMAP for state-funded termination of pregnancy services must include diagnosis code Z33.2 and modifier SE.
State-Funded Abortion Service Codes
| 01966 | Anesthesia for induced abortion procedures |
| 59812 | Treatment of incomplete abortion, any trimester, completed surgically |
| 59820 | Treatment of missed abortion, completed surgically; first trimester |
| 59821 | Treatment of missed abortion, completed surgically; second trimester |
| 59830 | Treatment of septic abortion, completed surgically |
| 59840 | Induced abortion, by dilation and curettage |
| 59841 | Induced abortion, by dilation and evacuation |
| 59850 | Induced abortion, by 1 or more intra-amniotic injections, including hospital admission and visits, delivery of fetus and secundines |
| 59851 | Induced abortion, by 1 or more intra-amniotic injections; with dilation and curettage |
| S0190 | Mifepristone, oral, 200 mg |
Prior Authorization, Billing Pathway, and Claim Submission
Prior authorization required; coordinate with DMAP Provider Services
First- and second‑trimester terminations require prior authorization. Coverage is limited to when the member's life is endangered if she were to carry the pregnancy to term, or when the pregnancy resulted from an act of rape or incest. Providers must contact DMAP Provider Services for historical utilization and remaining benefit information.
- Prior authorization required for first and second trimester terminations.
- Covered only if the member's life is endangered or the pregnancy resulted from rape or incest.
- Contact DMAP Provider Services for historical use and remaining benefit.
Billing pathway — bill state‑funded services through DMAP FFS and submit Z33.2 + modifier SE
State‑funded termination services must be billed through the DMAP fee‑for‑service (FFS) program. When submitting claims to DMAP for state‑funded abortion services, include diagnosis code Z33.2 and append modifier SE on the specified CPT/HCPCS line items.
- Bill state‑funded services through the FFS program (not MCO billing).
- Include diagnosis Z33.2 on the claim submission to DMAP.
- Include modifier SE on the claim line for state‑funded abortion service codes (see coding section for listed CPT/HCPCS codes).
- Contact DMAP Provider Services for historical utilization and remaining benefit prior to billing.
Definitions
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