CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Extended Family Planning (EFP) coverage and reimbursement requirements

Defines Neighborhood Health Plan of Rhode Island coverage, coding and reimbursement rules for the Medicaid Extended Family Planning (EFP) benefit for eligible female RIte Care members (postpartum or post-pregnancy loss and at risk of losing Medicaid eligibility).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Extended Family Planning (EFP) coverage and reimbursement requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date07/01/19

Next Review DateN/A

Key ActionVerify member eligibility, coverage and any required prior authorization (including for certain surgical treatments) before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1GYN annual exam per rolling year

Tables 1-8Coding tables provided (preventive, visits, sterilization, labs, surgical, interpreter, immunizations)

No cost sharingMember financial responsibility

EFP Enrollment, Covered Services, and Limitations

Enrollment eligibility for EFP benefit

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Medically necessary services covered under EFP

Covered services include but are limited to the CMS-approved list and the services below; services must be medically necessary:

ONE of the following (any)

One (1) gynecological annual exam per rolling year (11 months between) which includes a Pap testOne per rolling year with one month grace (11 months between)
Family planning related visits
Colposcopy
Repeat Pap smear as follow-up to abnormal Pap performed as part of routine/periodic family planning visit
Sterilization (when appropriately coded/authorized)
Some laboratory tests
Surgical treatment (including anesthesia) of major complications arising from a family planning procedure
Table 6 lists surgical/anesthesia codes; prior authorization required for surgical treatment per document
Interpreter and sign language services for family planning appointments
Some STI testing, Pap smears, pelvic exams, lab tests, and pregnancy testing
Some FDA approved methods of contraception
Contraceptive management, patient education and counseling
State supplied vaccinations and their administration

CPT, HCPCS, and ICD-10 Codes for EFP

EFP Annual Exam diagnosis codes (required with Table 1 CPT/HCPCS)ICD-10Covered

Z01.411	Encounter for gynecological examination (general) (routine) with abnormal findings of the breast
Z01.419	Encounter for gynecological examination (general) (routine) without abnormal findings of the breast

Notemixed

No codes listed

Table 1: Covered codes for EFP Annual ExamsCPT|HCPCSCovered

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

Notemixed

No codes listed

Table 2: Covered codes for EFP Family Planning Visits (when billed with listed diagnosis codes)CPTCovered

99201	Office/outpatient visit, new patient, problem focused (typically 10 minutes)
99202	Office/outpatient visit, new patient, expanded problem focused (typically 20 minutes)
99203	Office/outpatient visit, new patient, detailed (typically 30 minutes)
99204	Office/outpatient visit, new patient, comprehensive (typically 45 minutes)
99205	Office/outpatient visit, new patient, high complexity (typically 60 minutes)
99211	Office/outpatient visit, established patient, minimal (typically 5 minutes)
99212	Office/outpatient visit, established patient, problem focused (typically 10 minutes)
99213	Office/outpatient visit, established patient, expanded problem focused (typically 15 minutes)
99214	Office/outpatient visit, established patient, detailed (typically 25 minutes)
99215	Office/outpatient visit, established patient, high complexity (typically 40 minutes)

1–10 of 15

1/2

Notemixed

No codes listed

Table 2: Family planning visit diagnosis code ranges (allowed with above visit codes)ICD-10Covered

N30.00-N30.91	Cystitis and related disorders range
N34.0-N34.2	Urethritis and related disorders range
N70.01-N94.9	Inflammatory diseases of female pelvic organs and other female genital disorders range
Z01.42	Encounter for examination of breasts
Z03.011-Z30.9	Observation and certain family planning encounter codes range

Notemixed

No codes listed

Table 3: Sterilization diagnosis code (required)ICD-10Covered

Z30.2

Encounter for sterilization

Notemixed

No codes listed

Table 3: Covered sterilization and anesthesia codesCPT|HCPCSCovered

00851	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection
58565	Hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58600	Ligation or transection of fallopian tube(s), abdominal or vaginal approach
58611	Ligation/transsection when done at time of cesarean or intra-abdominal surgery (add-on)
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

Notemixed

No codes listed

Table 4: Laboratory testing diagnosis code range for labs (when billed with these codes)ICD-10Covered

Z30.011-Z30.9

Family planning encounter and contraceptive management range

Notemixed

No codes listed

Table 4: Covered laboratory and pathology CPT codes (selected list)CPTCovered

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

1–10 of 39

1/4

Notemixed

No codes listed

Table 5: Lab codes covered regardless of diagnosis billedCPTCovered

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

Notemixed

No codes listed

Table 6: Surgical treatment & anesthesia codes (may require prior authorization)CPT|HCPCS

00940	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); NOS
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, colporrhaphy, open urethral procedures
00944	Anesthesia for vaginal hysterectomy
00950	Anesthesia for culdoscopy
00952	Anesthesia for 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

1–10 of 37

1/4

Notemixed

No codes listed

Table 7: Interpreter servicesHCPCSCovered

T1013

Sign language or oral interpretive services, per 15 minutes

Notemixed

No codes listed

Table 8: Immunization administration codesCPTCovered

90460	Immunization administration through 18 yrs with counseling; first or only component
90461	Immunization administration through 18 yrs; each additional vaccine component
90471	Immunization administration; 1 vaccine, includes injection
90472	Immunization administration; each additional vaccine (list separately)
90473	Immunization administration by intranasal or oral route; 1 vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine

Notemixed

No codes listed

Required Actions, Billing Rules, and Denial Risks

Prior Authorization

Verify eligibility and prior authorization for services

Providers must verify member eligibility, coverage and authorization criteria prior to rendering services. Surgical treatment of major complications and certain surgical procedures listed in Table 6 may require prior authorization.

Table 6 surgical/anesthesia codes may require prior authorization

Documentation Required

Bill with required diagnosis codes

EFP Annual Exam (Table 1) must be billed with diagnosis code Z01.411 or Z01.419. Family planning visit and laboratory testing codes must be billed with the allowed diagnosis code ranges listed in the policy.

Z01.411
Z01.419
Z30.011-Z30.9
Z30.2
N30.00-N30.91
N34.0-N34.2
N70.01-N94.9
Z01.42
Z03.011-Z30.9

Denial Risk

Services outside CMS-approved EFP list may be denied

Claims for services that are not on the CMS‑approved EFP list or not enumerated in this policy are excluded and may be denied. Non‑formulary drugs are not covered under the EFP benefit.

Documentation Required

Coding and claims standards

All claims must comply with CPT, ICD-10-CM and HCPCS coding standards and be submitted within contractual timely filing guidelines. Adjustments, corrections, and reconsiderations must include the required forms and comply with national claims standards.

Key Thresholds

GYN annual exam intervalOne per rolling year with one month grace (11 months between)

Postpartum/post-loss eligibility window60 days post-partum or 60 days post pregnancy loss

Clinical and Program Background

The Extended Family Planning (EFP) benefit provides a limited set of family planning and related services to eligible female RIte Care members who are at risk of losing Medicaid eligibility. EFP is available for members who are above the Federal Poverty Level, have qualified for RIte Care, and are within the postpartum or post-pregnancy loss window of eligibility — specifically, members who are 60 days post-partum or 60 days post pregnancy loss and subject to losing Medicaid coverage.

Covered services under EFP are restricted to the CMS‑approved family planning benefits and related preventive and diagnostic services that are medically necessary. Examples include one gynecological annual exam (with Pap test) limited to one per rolling year (with an 11‑month interval/grace period), family planning visits, colposcopy, repeat Pap smears as follow-up to abnormal results, sterilization when appropriately coded/authorized, selected laboratory testing, surgical treatment (including anesthesia) for major complications of family planning procedures, interpreter/sign language services, certain STI testing and pregnancy testing, contraceptive methods and counseling, and state‑supplied vaccinations and their administration.

Limitations are explicit: the GYN annual exam is limited to one per rolling year, services outside the CMS‑approved EFP list are not covered, transportation is excluded from the EFP benefit package, and non‑formulary drugs will not be covered. Providers must verify member eligibility and any prior authorization requirements before rendering services, since some surgical treatments and procedures may require prior authorization.

OpenPayer

Medicaid Extended Family Planning (EFP) coverage and reimbursement requirements

EFP Enrollment, Covered Services, and Limitations

CPT, HCPCS, and ICD-10 Codes for EFP

Required Actions, Billing Rules, and Denial Risks

Clinical and Program Background

Defined Terms

Policy Dates