Neighborhood Health Plan RI EFP Coverage Update

Coverage criteria and scope

EFP Covered Services

Covered when ALL of the following are met

EFP member eligibility: Member is a female RIte Care enrollee above the Federal Poverty Level who was pregnant and is within 12 months post-partum or 12 months post-pregnancy loss and at risk of losing Medicaid eligibility.12 months

See Policy Statement

Service type: Service is within the CMS‑approved EFP list (examples: one gynecological annual exam per rolling year including Pap; family planning visits; colposcopy; repeat Pap for abnormal screening; sterilization; select laboratory testing; surgical treatment and associated anesthesia for major complications of family planning procedures; interpreter services; selected STI testing; FDA‑approved contraception; contraceptive management; state‑supplied vaccinations and administration).

See Medical Coverage list

Medical necessity and coding: Services are medically necessary, coded per CPT/ICD‑10‑CM/HCPCS, and billed with appropriate diagnosis and procedure codes as specified in the policy tables (e.g., Z01.411 or Z01.419 for annual exams).

Claims subject to coding, documentation, eligibility and benefit rules

Surgical Treatment Prior Authorization

Covered with prior authorization

Surgical/anesthesia procedures: Specific surgical procedures and associated anesthesia codes listed in Table 6 require prior authorization before coverage under EFP.prior authorization required

See Table 6 code list (anesthesia and surgical CPT codes)

Coverage groups by Table

Services in the tables may be covered as specified:

Table 5 Laboratory Services: Table 5 service codes (e.g., 81001, 88174, 88175, 88365) may be covered for EFP Laboratory Testing Services regardless of diagnosis billed.

Table 5 lab codes may be covered regardless of diagnosis

Table 6 Surgical/Anesthesia Services: Table 6 service codes (comprehensive list of anesthesia and gynecologic surgical CPT codes) may be covered for EFP Surgical Treatment only with prior authorization.prior authorization required

Extensive list of CPT/Anesthesia codes in Table 6

Table 7 Interpreter Services: Table 7 interpreter service code T1013 (sign language/oral interpretive services, per 15 minutes) may be covered for EFP interpreter services.

HCPCS T1013 per 15 minutes

Code-based coverage

Covered procedures and services (code listing)

Code listing: Procedures and services enumerated in Tables 2, 5, 6, 7, and 8 (including family planning visits/procedures, laboratory/pathology codes, sterilization and anesthesia codes, extensive gynecologic surgical CPT codes, interpreter services T1013, and immunization administration codes 90460–90474) are included as potentially covered when billed consistent with member benefits, coding, documentation, authorization (when required), and eligibility rules.

See Tables 2, 5–8 for full code lists

EFP excludes services that are not part of the CMS-approved EFP service list. Transportation services are explicitly excluded from the EFP benefit package, and non‑formulary drugs will not be covered under EFP.

Specific surgical and related anesthesia services listed in Table 6 require prior authorization for coverage under the EFP benefit. Providers should obtain authorization before performing these procedures; failure to secure prior authorization may result in claim denial.

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

Any service not included on the CMS‑approved EFP service list or otherwise outside the scope described in this policy is not covered as part of the EFP benefit.

There are no explicit statements in this policy text labeling specific services as "not medically necessary."

CPT / HCPCS / ICD-10 coding tables

Allowed ICD-10 Diagnosis Codes for EFP Annual ExamsICD-10Covered

Z01.411	Encounter for routine gynecological examination with abnormal findings
Z01.419	Encounter for routine gynecological examination without abnormal findings

Covered CPT/HCPCS Codes — Annual Exams (Table 1)mixedCovered

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

Covered CPT Codes — Family Planning Visits and Procedures (Table 2)CPTCovered

99202	Office/outpatient visit, new patient, expanded problem focused history/exam, straightforward MDM (~20 minutes)
99203	Office/outpatient visit, new patient, detailed history/exam, low complexity MDM (~30 minutes)
99204	Office/outpatient visit, new patient, comprehensive history/exam, moderate complexity MDM (~45 minutes)
99205	Office/outpatient visit, new patient, comprehensive history/exam, high complexity MDM (~60 minutes)
99211	Office/outpatient visit, established patient, minor problem (~5 minutes)
99212	Office/outpatient visit, established patient, problem focused history/exam, straightforward MDM (~10 minutes)
99213	Office/outpatient visit, established patient, expanded problem focused history/exam, low complexity MDM (~15 minutes)
99214	Office/outpatient visit, established patient, detailed history/exam, moderate complexity MDM (~25 minutes)
99215	Office/outpatient visit, established patient, comprehensive history/exam, high complexity MDM (~40 minutes)
11976	Removal, implantable contraceptive capsules

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Covered CPT/Anesthesia Codes — Sterilization (Table 3)CPTCovered

00851	Anesthesia for intraperitoneal procedures in lower abdomen incl. 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), abdominal or vaginal approach
58611	Ligation or transection of fallopian tube(s) when done at time of cesarean or intra-abdominal surgery (not separate)
58615	Occlusion of fallopian tube(s) by device (eg band, clip, Falope ring) vaginal or suprapubic approach
58670	Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671	Laparoscopy, surgical; with occlusion of oviducts by device (eg band, clip, Falope ring)

Covered Laboratory and Pathology Codes (Tables 4 & 5)mixedCovered

81000	Urinalysis, by dip stick or tablet reagent; non-automated, with microscopy
81002	Urinalysis, by dip stick or tablet reagent; 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, visual color comparison
85013	Blood count; spun microhematocrit
85014	Blood count; hematocrit (Hct)

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Table 6 — Surgical/anesthesia codes (prior authorization required)mixedCovered

00940	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium)
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, colporrhaphy, 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 5: EFP Laboratory Testing Services (may be covered regardless of diagnosis billed)CPTCovered

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

Table 6: EFP Surgical Treatment and related CPT/Anesthesia codes (may be covered with prior authorization)mixedCovered

00940	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium)
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, colporrhaphy, 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 7: EFP Interpreter ServicesHCPCSCovered

T1013

Sign language or oral interpretive services, per 15 minutes

Gynecologic surgical CPT codesCPT

57330

Closure of vesicovaginal fistula; transvesical and vaginal approach

Interpreter services HCPCSHCPCSCovered

T1013

Sign language or oral interpretive services, per 15 minutes

Immunization administration CPT codes (pediatrics)CPTCovered

90460	Immunization administration through 18 years; first or only component with counseling
90461	Immunization administration through 18 years; each additional vaccine component
90471	Immunization administration; 1 vaccine (single or combo) — injection
90472	Immunization administration; each additional vaccine — injection
90473	Immunization administration by intranasal or oral route; 1 vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine

GYN annual exam frequencymixed

Frequency

One (1) gynecological annual exam per rolling year (minimum 11 months between)

EFP eligibility windowmixed

Eligibility

Up to 12 months post-partum or up to 12 months after pregnancy loss for eligible female RIte Care members at risk of losing Medicaid

Eligibility timeframemixed

12 months

Eligibility timeframe — 12 months

Provider responsibilities, prior authorization, and billing

Prior Authorization

Provider actions — prior authorization, out-of-scope services, and billing

Prior authorization is required for certain surgical and anesthesia procedures and for any services listed in Table 6. Providers must verify member eligibility and obtain prior authorization before scheduling or performing these procedures to avoid claim denials.

Table 6 surgical and anesthesia codes (see policy Table 6) require prior authorization before EFP surgical treatment will be covered.
Services outside the CMS-approved EFP list and non-formulary drugs are excluded from coverage and may be denied; providers should confirm that requested services are within the EFP benefit.
When submitting claims for Table 6 services, include the specific procedure/CPT codes and attach prior authorization documentation or authorization reference numbers as required by Neighborhood.
Failure to verify eligibility, coverage, and authorization prior to rendering services may result in denied claims; all services billed to Neighborhood are subject to audit and must meet coding and documentation guidelines.

Background and purpose

Extended Family Planning (EFP) provides a limited set of family‑planning related services to eligible female RIte Care members for up to 12 months following delivery (post‑partum) or following pregnancy loss. Covered services include one annual gynecologic exam per rolling year, family planning visits and procedures, selected laboratory and pathology testing, sterilization services, surgical treatment of major complications when authorized, interpreter services, selected STI and contraceptive services, and state‑supplied vaccinations when applicable.

Key definitions

EFP eligibility — inv-39

DefinitionFemale RIte Care members above the Federal Poverty Level who were pregnant and are now within 12 months post‑partum or 12 months post‑pregnancy loss and are at risk of losing Medicaid eligibility

Coverage durationUp to 12 months following delivery or pregnancy loss

Population scopeApplies to members who previously qualified for RIte Care during pregnancy

GYN annual exam — inv-40

AllowanceOne gynecological annual exam per rolling year (11 months between) — includes a Pap test

Grace periodOne‑month grace period permitted between rolling‑year exams

OpenPayer

Medicaid Extended Family Planning (EFP) coverage

Coverage criteria and scope

CPT / HCPCS / ICD-10 coding tables

Provider responsibilities, prior authorization, and billing

Background and purpose

Key definitions