Neighborhood Health Plan RI EFP Coverage Update

Coverage Criteria and Medical Necessity

Medical necessity and covered services

Covered services when eligibility and medical necessity are met

EFP member eligibility: Member is a female RIte Care enrollee who meets EFP eligibility (above the Federal Poverty Level, qualified for RIte Care) and includes those up to 12 months postpartum12 months postpartum eligibility noted

See policy statement for eligibility details

Covered service categories

Preventive and visit services: One (1) gynecological annual exam per year (rolling period; 11 months between allowed) and family planning related visits, including contraceptive management, patient education and counselingOne per year rolling (11 months between)
Procedures and treatments: Colposcopy; sterilization; surgical treatment (including anesthesia) of major complications from family planning procedures; some STI testing/treatment; repeat Pap for abnormal results; some laboratory and pathology services; insertion/removal of contraceptive implants; state-supplied vaccinations and administration
Pharmacy and vaccines: Allowable pharmaceuticals must be on the Neighborhood formulary (e.g., drugs for vaginal/urinary infections and treatment of STIs except HIV/AIDS/hepatitis as specified) and state-supplied vaccines when billed appropriately
Ancillary services: Interpreter and sign language services for family planning appointments

Covered when code is listed

Codes that may be covered for EFP Surgical Treatment (per tables):

Listed CPT/HCPCS codes for EFP Surgical Treatment

Laboratory / Cytology example codes: Examples: 81001, 88174, 88175, 88365
Surgical treatment and anesthesia example codes (may require prior auth): Examples: 00940, 00942, 00944, 00950, 00952, 11981, 11982, 11983, 56405, 56420, 56440, 56441, 56442, 56501
Table 6 heading: 'may be covered for EFP Surgical Treatment with prior authorization' and specific surgical codes listed

Services that fall outside the CMS-approved list for the Extended Family Planning (EFP) benefit are excluded from coverage and may be denied. In addition, transportation is not part of the EFP benefit package, and non‑formulary drugs will not be covered under EFP.

No additional explicit exclusions are identified in the source tables or policy text beyond those already stated; providers should refer to the listed service tables to determine whether a specific code or service is included for EFP coverage.

This payment policy is informational only and is not a guarantee of reimbursement. Claim payment is contingent upon member eligibility, benefit coverage, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. All services billed to Neighborhood are subject to audit.

Any service that is not included within the limited CMS‑approved EFP list of services is not covered under the EFP benefit; such services must be billed and adjudicated outside of the EFP benefit if applicable.

The policy text does not include explicit statements labeling services as 'not medically necessary' beyond the exclusion that services outside the CMS‑approved EFP list are not covered. Providers should use the included tables and eligibility rules to determine coverage and medical necessity.

Billing and Code Lists

EFP Annual Exam codesmixedCovered

201.411	Diagnosis code listed as acceptable for EFP Annual Exams
201.419	Diagnosis code listed as acceptable for EFP Annual Exams
99394	Periodic comprehensive preventive medicine reevaluation and management - adolescent (12-17)
99395	Periodic comprehensive preventive medicine reevaluation and management - 18-39
99396	Periodic comprehensive preventive medicine reevaluation and management - 40-64
S0610	Annual gynecological examination, new patient
S0612	Annual gynecological examination, established patient

EFP Family Planning Visit and contraceptive procedure codesmixedCovered

N30.00-N30.91	Urinary tract related diagnosis code range referenced for family planning visits
N34.0-N34.2	Urethritis/urethral syndrome diagnosis range
N70.01-N94.9	Pelvic inflammatory and other female genital diagnoses range
Z01.42	Encounter for gynecological examination (general)
Z03.011-Z30.9	Encounter/exposure and contraception codes range
99202	Office/outpatient visit new patient, expanded problem focused
99203	Office/outpatient visit new patient, detailed
99204	Office/outpatient visit new patient, comprehensive
99205	Office/outpatient visit new patient, high complexity
99211	Office/outpatient visit established patient, minimal

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EFP Sterilization and related anesthesia codesmixedCovered

00851	Anesthesia for intraperitoneal procedures including laparoscopy; tubal ligation/transection
58565	Hysteroscopy with bilateral fallopian tube cannulation for permanent implants
58600	Ligation or transection of fallopian tube(s)
58611	Ligation/transection of fallopian tube(s) at time of cesarean/intra-abdominal surgery
58615	Occlusion of fallopian tube(s) by device (band, clip, Falope ring)
58670	Laparoscopy with fulguration of oviducts
58671	Laparoscopy with occlusion of oviducts by device

EFP Laboratory and pathology codesmixedCovered

81000-81025	Various urinalysis and urine pregnancy test codes
85013	Blood count; spun microhematocrit
85014	Blood count; hematocrit (Hct)
85018	Blood count; hemoglobin (Hgb)
86255	Fluorescent noninfectious agent antibody; screen
86592	Syphilis test; non-treponemal antibody; qualitative
86593	Syphilis test; non-treponemal antibody; quantitative
86631	Antibody; Chlamydia
86632	Antibody; Chlamydia, IgM
86689	Antibody; HTLV or HIV antibody, confirmatory test

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EFP Surgical Treatment (prior auth may be required)mixedCovered

00940	Anesthesia for vaginal procedures
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, etc.
00944	Anesthesia for vaginal procedures; vaginal hysterectomy biopsy
00950	Anesthesia for vaginal procedures; culdoscopy biopsy
00952	Anesthesia for vaginal procedures; hysteroscopy/hysterosalpingography
11981	Insertion, non-biodegradable drug delivery implant
11982	Removal, non-biodegradable delivery implant drug
11983	Removal with reinsertion, non-biodegradable drug delivery implant
56405	Incision and drainage of vulva or perineal abscess
56420	Incision and drainage of Bartholin's gland abscess

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Laboratory / Cytology codes (Table 2 excerpt)CPT

81001	Urinalysis, by dip stick or tablet reagent - automated, with microscopy
88174	Cytopathology, cervical or vaginal - automated thin layer preparation; screening by automated system
88175	Cytopathology, cervical or vaginal - automated screening with manual rescreening/review
88365	In situ hybridization (eg, FISH), per specimen; initial single probe

Covered CPT Codes (Tables 6 and supporting Table 2 excerpts)CPTCovered

00940	Anesthesia for vaginal procedures; not otherwise specified
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, colporrhaphy, and open urethral procedures
00944	Anesthesia for vaginal procedures; vaginal hysterectomy biopsy
00950	Anesthesia for vaginal procedures; culdoscopy biopsy
00952	Anesthesia for vaginal procedures; hysteroscopy and/or hysterosalpingography
11981	Insertion, non-biodegradable drug delivery implant
11982	Removal, non-biodegradable delivery implant drug
11983	Removal with reinsertion, non-biodegradable drug delivery implant
56405	Incision and drainage of vulva or perineal abscess
56420	Incision and drainage of Bartholin's gland abscess

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Interpreter Services (Table 7)HCPCSCovered

T1013

Language or oral interpretive services, per 15 minutes

Covered CPT Codes (gynecologic surgeries, ectopic pregnancy, related procedures)CPTCovered

58943	Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy.
58950	Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy.
58951	Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, and limited para-aortic lymphadenectomy pelvic.
58952	Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for retroperitoneal tumors.
58953	Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking.
58954	Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with lymphadenectomy and limited para-aortic lymphadenectomy pelvic.
58956	Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy.
58957	Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy if performed.
58958	Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy if performed; with lymphadenectomy and limited para-aortic lymphadenectomy pelvic.
58960	Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing; of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy biopsy.

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Potentially covered ancillary service codes (Interpreter Services)HCPCSCovered

T1013

Language or oral interpretive services, per 15 minutes.

Immunization and Vaccine Administration Codes (when billed with state supplied vaccine)CPTCovered

90460	Immunization administration through 18 years of age via any route, with counseling; first or only component of each vaccine or toxoid administered.
90461	Immunization administration through 18 years of age; each additional vaccine or toxoid component administered.
90471	Immunization administration; 1 vaccine (single or combination vaccine/toxoid).
90472	Immunization administration; each additional vaccine (single or combination vaccine/toxoid).
90473	Immunization administration by intranasal or oral route; 1 vaccine.
90474	Immunization administration by intranasal or oral route; each additional vaccine.

GYN annual exam frequency

Allowed frequencyOne (1) gynecological annual exam per rolling year (11 months between allowed).

Included with examExam includes a test and rolling period Pap when indicated.

Coverage noteLimited to one per year as a coverage limitation under EFP.

uterus weight threshold

Uterus weight threshold

Provider Requirements, Prior Authorization, and Billing Guidance

Denial Risk

Services Outside CMS Approved List Not Covered

Services outside the CMS-approved list for the EFP benefit are not covered and may be denied. Providers should confirm that any requested service is included on the CMS-approved EFP list prior to scheduling or performing the service.

EFP excludes any services not on the CMS approved list.

Prior Authorization

Prior Authorization May Be Required

Some surgical treatment codes listed in the policy may be covered only with prior authorization. Providers must obtain prior authorization when codes are noted as requiring it to avoid claim denials or payment delays.

Examples: select anesthesia and minor surgical procedure codes in Table 6 may require prior authorization.
Verify prior authorization status for EFP surgical treatment codes before rendering services.

Policy Background

Extended Family Planning (EFP) provides a limited set of family‑planning and related services for eligible female RIte Care members, including one annual gynecologic exam, family planning visits and contraceptive procedures, selected laboratory and cytology tests (for example 81001, 88174–88175, 88365), sterilization procedures, some surgical treatments, STI testing/treatment, interpreter services, and state‑supplied immunizations when billed with the appropriate administration codes. Eligibility references the postpartum period up to 12 months and other RIte Care qualifying criteria. Providers should consult the policy tables for the exact list of covered procedure and HCPCS/CPT codes and prior authorization requirements.

Key Terms and Definitions

Extended Family Planning (EFP)

DefinitionExtended Family Planning (EFP): the Medicaid-based family planning benefit available to eligible female RIte Care members as described in this policy.

Eligibility scopeAvailable to female RIte Care members above the Federal Poverty Level who qualified for RIte Care, including those up to 12 months postpartum.

Covered services overviewIncludes annual gynecologic exam, family planning visits, contraceptive services, select labs, some surgical treatments, STI testing/treatment, interpreter services, and state-supplied vaccinations.

EFP Surgical Treatment

GroupingEFP Surgical Treatment: grouping referenced for female pelvic/female reproductive procedures covered under the policy (see Table 6 and supporting tables).

Examples included

Policy Revision History

2022-10-01annual_reviewLatest

Annual policy review; policy statement eligibility period revised from 60 to 12 months and CPT 57112 removed from the policy.

2021-09-29annual_review

Annual policy review recorded; no content changes noted.

2020policy_review

Policy review noted with format updates applied to the policy.

OpenPayer

Extended Family Planning (EFP) coverage — Medicaid EFP benefit for female RIte Care members