Neighborhood Health Plan EFP Coverage & Prior Auth

Extended Family Planning (EFP) Coverage Criteria

Covered Services

Covered EFP services (limited to CMS‑approved list) include:

Covered service list: One (1) gynecological annual exam per year (rolling with a one‑month grace period); family planning related visits; repeat Pap smear as follow‑up to an abnormal Pap when performed as part of a routine/periodic family planning visit; colposcopy; sterilization; select laboratory tests; surgical treatment (including anesthesia) of major complications arising from a family planning procedure; select sexually transmitted infection (STI) testing, smears and exams; interpreter and sign language services for family planning appointments; some FDA‑approved contraceptive methods; state‑supplied vaccinations and their administration; contraceptive management, patient education and counseling.

Services limited to CMS‑approved EFP list.

Pharmacy Coverage

Pharmacy coverage conditions:

Pharmacy coverage: Allowable pharmaceuticals must be listed on the Neighborhood formulary. Drugs for treatment of identified vaginal, lower genital tract, skin, and urinary tract infections and drugs for identified AIDS/hepatitis related to an identified STI when diagnosed during a routine/periodic family planning visit may be covered.

Non‑formulary drugs will not be covered.

Medical Necessity and Claims

Medical necessity and billing requirements:

Medical necessity: All services must be medically necessary; Neighborhood may apply NCD, LCD, EOHHS recommendations, InterQual, and Clinical Medical Policies (CMP) to determine medical necessity.

Provider responsibility to verify eligibility, coverage and authorization criteria before rendering services.

Claim submission: Providers must submit complete claims for payment within timely filing guidelines and in compliance with national claims standards (CPT, ICD‑10‑CM, and HCPCS Level II); adjustments, corrections and reconsiderations must include required forms.

Billable services are subject to contractual agreements and timely filing rules.

EFP Laboratory Testing Services

Laboratory services coverage note

Laboratory services covered regardless of diagnosis: The service codes listed in Table 5 (examples: 81001, 88174, 88175, 88365) may be covered for EFP Laboratory Testing Services regardless of the diagnosis billed.

From Table 5.

EFP Surgical Treatment

Surgical services coverage note

Surgical services may require prior authorization: The service codes listed in Table 6 (EFP Surgical Treatment) may be covered only with prior authorization.

See Table 6; prior authorization is required for listed surgical procedure codes.

Summary of exclusions: Extended Family Planning (EFP) does not cover services that fall outside the CMS-approved list of EFP services. Transportation is explicitly not part of the EFP benefit package. In addition, non-formulary drugs will not be covered under the EFP benefit.

Informational payment notice: this policy is informational only and is not a guarantee of reimbursement. Claim payment is subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. Providers should verify eligibility and applicable authorization requirements prior to rendering services.

Explicit exclusion: any service not included on the CMS-approved EFP service list is not covered for EFP members. Providers should not bill Neighborhood for services outside that approved list under the EFP benefit.

Codes and Frequency Rules for EFP Services

Covered CPT/HCPCS Codes - EFP Annual ExamsmixedCovered

99394	Periodic comprehensive preventive medicine reevaluation and management; adolescent 12-17 years
99395	Periodic comprehensive preventive medicine reevaluation and management; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management; 40-64 years
S0610	Annual gynecological examination, new patient
S0612	Annual gynecological examination, established patient

Covered CPT Codes - EFP Family Planning Visits & ProceduresCPTCovered

99201	Office/outpatient visit, new patient, problem focused
99202	Office/outpatient visit, new patient, expanded problem focused
99203	Office/outpatient visit, new patient, detailed history/exam
99204	Office/outpatient visit, new patient, comprehensive
99205	Office/outpatient visit, new patient, high complexity
99211	Office visit, established patient; typically minimal
99212	Office visit, established patient; problem focused
99213	Office visit, established patient; expanded problem focused
99214	Office visit, established patient; detailed
99215	Office visit, established patient; high complexity

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Covered CPT/Anesthesia Codes - EFP SterilizationmixedCovered

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

Covered Laboratory and Cytology Codes - EFPCPTCovered

81000	Urinalysis, non-automated, with microscopy
81002	Urinalysis, non-automated, without microscopy
81003	Urinalysis, automated, without microscopy
81005	Urinalysis; qualitative or semiquantitative, except immunoassays
81007	Urinalysis; bacteriuria screen
81015	Urinalysis; microscopic only
81020	Urinalysis; 2 or 3 glass test
81025	Urine pregnancy test, by visual color comparison
85013	Blood count; spun microhematocrit
85014	Blood count; hematocrit (Hct)

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Diagnosis codes associated with EFP Annual ExamsICD-10

Z01.411	Encounter for gynecological examination (with abnormal findings) - listed for Annual Exam
Z01.419	Encounter for gynecological examination (without abnormal findings) - listed for Annual Exam

Diagnosis codes associated with EFP Family Planning VisitsICD-10

N30.00-N30.91	Codes range for bladder/urinary conditions listed for family planning visits
N34.0-N34.2	Urethritis/urethral syndrome codes
N70.01-N94.9	Inflammatory disease of female pelvic organs and other gynecologic codes
Z01.42	Encounter for gynecological examination; pelvic exam
Z03.011-Z30.9	Observation and encounters related to contraception and other family planning

Cytopathology and surgical pathology CPT codesCPTCovered

88141	Cytopathology, cervical or vaginal; collected in preservative fluid, automated thin layer; manual screening under physician supervision
88143	Cytopathology, cervical or vaginal; with manual screening and rescreening under physician supervision
88147	Cytopathology smears; screening by automated system under physician supervision
88148	Cytopathology smears; automated with manual rescreening under physician supervision
88150	Cytopathology, slides; manual screening under physician supervision
88155	Cytopathology, definitive hormonal evaluation
88164	Cytopathology, manual screening (Bethesda System)
88165	Cytopathology with manual screening and rescreening (Bethesda System)
88166	Cytopathology with computer-assisted rescreening (Bethesda System)
88167	Cytopathology with computer-assisted rescreening using cell selection and review

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Laboratory codes covered regardless of diagnosisCPTCovered

81001	Urinalysis, automated, with microscopy
88174	Cytopathology, collected in preservative fluid; automated thin layer; screening by automated system
88175	Cytopathology, automated thin layer; with screening by automated system and manual rescreening or review
88365	In situ hybridization (eg, FISH), per specimen; initial single stain procedure/probe

EFP Surgical and related CPT codes (Table 4 & Table 6)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
00950	Anesthesia for vaginal procedures; culdoscopy
00952	Anesthesia for vaginal procedures; hysteroscopy and/or hysterosalpingography
11981	Insertion, non-biodegradable drug delivery implant
11982	Removal, non-biodegradable drug delivery implant
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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Table 4 procedure CPT codesCPT

58661	Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58662	Laparoscopy, surgical; with fulguration or excision of lesions of the ovary
58740	Lysis of adhesions (salpingolysis, ovariolysis)
58800	Drainage of ovarian cyst(s), vaginal approach
58805	Drainage of ovarian cyst(s), abdominal approach
58820	Drainage of ovarian abscess; vaginal approach, open
58822	Drainage of ovarian abscess; abdominal approach
58825	Transposition, ovary(s)
58900	Biopsy of ovary, unilateral or bilateral
58920	Wedge resection or bisection of ovary

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Table 7 - Interpreter servicesHCPCS

T1013

Sign language or oral interpretive services, per 15 minutes

Table 8 - Immunization administration codesCPT

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
90472	Immunization administration (injectable); each additional vaccine (single or combination)
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

FrequencyOne (1) gynecological annual exam per year (rolling) with a one‑month grace period — effectively 11 months between allowed exams.

Included servicesAnnual exam may include routine Pap testing when provided as part of the exam.

LimitationGYN annual exam is limited to one per 12‑month rolling period; providers should track dates to ensure compliance with the 1‑year/1‑month rule.

Uterus weight threshold for certain hysterectomy codes

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain surgical services listed in Table 6. Providers must obtain authorization prior to scheduling or performing these procedures; services provided without prior authorization may be denied or payment reduced.

Affected codes: surgical procedures listed in Table 6 (see policy Tables)
Prior authorization must be verified and approved before service delivery

Denial Risk

Payment and Denial Risk

Payments are subject to member eligibility, benefit coverage, authorization status, and claims edits. Even when prior authorization is obtained, Neighborhood may deny or adjust payment if the member is not eligible at time of service or if documentation or coding does not support the billed service.

Verify member eligibility and benefits at the time of service

Policy Background

Background: Extended Family Planning (EFP) is a limited Medicaid benefit for eligible female Rhode Island members that provides a defined set of family-planning and related services (for example: one annual gynecologic exam per year, family planning visits and counseling, certain contraceptive services, selected laboratory and cytology testing, sterilization procedures, and related preventive care). Coverage is constrained to the services approved by CMS for the EFP program and is intended to support contraceptive management, STI testing, and related preventive services for qualifying members.

Definitions and Eligibility

EFP eligibility

Eligible populationFemale RIte Care members eligible for Extended Family Planning (EFP).

Income/eligibility noteMembers above the Federal Poverty Level (FPL) may qualify for EFP as described in policy statement.

Timing postpartum/post‑lossIncludes postpartum members and those at least 60 days after pregnancy loss as eligible for EFP services.

EFP Laboratory Testing Services

DefinitionEFP Laboratory Testing Services are laboratory and cytopathology procedures that may be covered regardless of diagnosis when listed (examples below).

ExamplesUrinalysis (81001), cervical/vaginal cytopathology automated thin‑layer screening (88174, 88175), and in situ hybridization (88365).

OpenPayer

Extended Family Planning (EFP) services coverage

Extended Family Planning (EFP) Coverage Criteria

Codes and Frequency Rules for EFP Services

Provider Requirements, Prior Authorization, and Documentation

Policy Background

Definitions and Eligibility