CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Extended Family Planning (EFP) coverage and reimbursement requirements

Defines medical coverage, limitations, coding, and reimbursement requirements for Extended Family Planning (EFP) services for Rhode Island Medicaid (EFP) members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyExtended Family Planning (EFP) coverage and reimbursement requirements

Policy CodePolicy N/A

Change TypeClarified (non-material)

Effective DateJul 1, 2019

Next Review Date

Key ActionVerify member eligibility, confirm coverage and prior authorization requirements (especially for surgical codes listed in Table 6), and submit documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Document history shows policy review and effective date updates (07/01/2019 effective; 09/28/2020 review date update). No explicit material coverage changes are documented in this text.

1GYN annual exam allowed per 12 months (rolling)

MultipleCode tables provided (Preventive, E/M, Sterilization, Labs, Surgical, Interpreter, Immunization)

Prior authCertain surgical treatment codes require prior authorization

Extended Family Planning (EFP) Coverage Conditions

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General EFP eligibility and medical necessity

EFP is available under the following member- and medical-necessity-based conditions:

ALL of the following

Member is a female RIte Care (Medicaid) member eligible for EFP
Member income is above Federal Poverty Level (FPL) and subject to Medicaid eligibility
Member is postpartum OR at least 60 days have passed since pregnancy loss
Policy text indicates postpartum or 60 days after pregnancy loss eligibility
Services must be medically necessary
Neighborhood may apply NCDs, LCDs, EOHHS recommendations, InterQual, and Clinical Medical Policies to determine medical necessity

Coverage for Gynecologic Annual Exam

Covered when billed with an appropriate diagnosis code and limited to one per rolling 12-month period (11 months between exams allowed):

ALL of the following

One gynecological annual exam per year (rolling) including testing (Pap/Pelvic as appropriate)
Allowed CPT/HCPCS for annual exam (must be billed with one of the listed diagnosis codes)
- CPT 99394 (adolescent 12-17)
- CPT 99395 (18-39)
- CPT 99396 (40-64)
- HCPCS S0610 (annual gynecological exam, new patient)
- HCPCS S0612 (annual gynecological exam, established patient)
Permissible diagnosis codes for annual exam
- Z01.411
- Z01.419

Family Planning Visits and Related Services

Covered when appropriate E/M or family planning procedure codes are billed with relevant diagnosis codes listed below:

ALL of the following

Allowed diagnosis code ranges for family planning visits
- N30.00 - N30.91 (cystitis/urethritis codes range listed)
- N34.0 - N34.2
- N70.01 - N94.9
- Z01.42
- Z03.011 - Z30.9
Allowed E/M and procedure codes for family planning visits
- CPT 99201-99205 (new patient E/M series)
- CPT 99211-99215 (established patient E/M series)
- CPT 11976 (removal, implantable contraceptive capsules)
- CPT 57170 (diaphragm or cervical cap fitting with instructions)
- CPT 58300 (IUD insertion)
- CPT 58301 (IUD removal)
Family planning related visits include counseling, contraceptive management, STI testing, repeat Pap follow-up, colposcopy, sterilization, interpreter services, and state-supplied vaccinations

Sterilization

Sterilization procedures are covered when billed with diagnosis Z30.2 and subject to listed procedure codes:

ALL of the following

Diagnosis code Z30.2 must accompany sterilization procedure
ANY of the following
- CPT 00851 (anesthesia for intraperitoneal procedures including tubal ligation)
- CPT 58565 (hysteroscopy with bilateral fallopian tube cannulation/placement of permanent implants)
- CPT 58600 (ligation/transection of fallopian tube(s))
- CPT 58611 (ligation at time of cesarean/intra-abdominal surgery)
- CPT 58615 (occlusion of fallopian tubes by device)
- CPT 58670 (laparoscopy with fulguration of oviducts)
- CPT 58671 (laparoscopy with occlusion of oviducts by device)

Laboratory and Diagnostic Testing

A broad set of lab and cytology codes are covered for EFP when billed with appropriate family planning or related diagnosis codes (many codes listed).

ANY of the following

Urinalysis codes: 81000, 81002, 81003, 81005, 81007, 81015, 81020, 81025, 81001
Hematology: 85013, 85014, 85018
Serology/STD testing: 86255, 86592, 86593, 86631, 86632, 86689, 86694, 86695, 86701, 86702, 86703, 86780
Microbiology/culture/smear: 87081, 87110, 87206, 87207
Cytology/Pap: 88141-88150, 88155, 88164-88167, 88174, 88175
Surgical pathology: 88302, 88365
Endometrial sampling/biopsy/D&C: 58100, 58110, 58120

Surgical Treatment (including anesthesia) of major complications and specified procedures

Many surgical procedures are listed as potentially covered; some surgical treatments require prior authorization.

ALL of the following

Surgical treatment of major complications arising from a family planning procedure is covered
Certain surgical treatment codes require prior authorization (Table 6)
Examples of surgical/anesthesia codes (extensive list provided in Tables 4 & 6)
- Anesthesia for vaginal procedures: 00940, 00942, 00944, 00950, 00952
- Insert/remove contraceptive implants: 11981, 11982, 11983
- Wide range of vulvar/vaginal/uterine/ovarian/adnexal procedures: CPTs 56405-58999 (numerous specific codes listed in policy)
- Surgical treatment codes listed in Table 6 are subject to prior authorization

Interpreter and Vaccine Services

Interpreter services and state-supplied immunizations are covered under EFP when billed with appropriate codes or state vaccine supply:

ALL of the following

- HCPCS T1013 (sign language/oral interpretive services, per 15 minutes)
- Immunization administration codes: 90460, 90461, 90472, 90473, 90474 (as applicable when billed with state-supplied vaccine)

Relevant Procedure, Diagnosis, and Other Codes

Annual gynecologic exam codesCPT|HCPCS|ICD-10Covered

99394	Periodic comprehensive preventive medicine, adolescent 12-17 (covered for EFP annual exam)
99395	Periodic comprehensive preventive medicine, 18-39 (covered for EFP annual exam)
99396	Periodic comprehensive preventive medicine, 40-64 (covered for EFP annual exam)
S0610	Annual gynecological examination, new patient
S0612	Annual gynecological examination, established patient
Z01.411	Encounter for gynecological exam (pelvic) with abnormal findings — allowed diagnosis for annual exam
Z01.419	Encounter for gynecological exam (pelvic) without abnormal findings — allowed diagnosis for annual exam

Family planning E/M and procedure codesCPT|ICD-10Covered

99201	Office visit, new patient (listed as covered for family planning visits)
99202	Office visit, new patient
99203	Office visit, new patient
99204	Office visit, new patient
99205	Office visit, new patient
99211	Office visit, established patient, minimal
99212	Office visit, established patient
99213	Office visit, established patient
99214	Office visit, established patient
99215	Office visit, established patient

1–10 of 15

1/2

Family planning diagnosis codesICD-10

N30.00-N30.91	Range for cystitis/related urinary conditions (listed as acceptable diagnoses)
N34.0-N34.2	Other urethritis codes range
N70.01-N94.9	Range for inflammatory disease of female pelvic organs to other female genital disorders
Z01.42	Encounter for gynecological examination (general) — listed
Z03.011-Z30.9	Observation for suspected conditions/encounters for contraceptive management (range)

Sterilization codesCPT|ICD-10Covered

Z30.2	Encounter for sterilization
00851	Anesthesia for intraperitoneal procedures (includes tubal ligation)
58565	Hysteroscopy with bilateral fallopian tube cannulation/permanent implants
58600	Ligation/transection of fallopian tubes
58611	Ligation at time of cesarean/intra-abdominal surgery
58615	Occlusion of fallopian tubes by device
58670	Laparoscopy with fulguration of oviducts
58671	Laparoscopy with occlusion of oviducts by device

Laboratory and cytology codes (selected)CPT|HCPCSCovered

81000	Urinalysis with microscopy
81001	Urinalysis automated with microscopy
81025	Urine pregnancy test, visual
85013	Blood count; spun microhematocrit
86592	Syphilis test, non-treponemal; qualitative
86631	Antibody; Chlamydia
87081	Culture, presumptive, pathogenic organisms, screening only
87110	Culture, chlamydia, any source
88141	Cytopathology, cervical or vaginal, screening
88174	Cytopathology, thin layer prep; automated screening

1–10 of 12

1/2

Surgical treatment codes (extensive list)CPTCovered

00940	Anesthesia for vaginal procedures
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy
00944	Anesthesia for vaginal hysterectomy
11981	Insertion, non-biodegradable delivery implant drug
11982	Removal, non-biodegradable drug delivery implant
56405	Incision and drainage of vulva/perineal abscess
56605	Biopsy of vulva/perineum
57170	Diaphragm or cervical cap fitting
57288	Sling operation for stress incontinence
57400	Dilation of vagina under anesthesia

1–10 of 20

1/2

Interpreter servicesHCPCSCovered

T1013

Sign language/oral interpretive services, per 15 minutes

Immunization administration (state-supplied vaccine)CPTCovered

90460	Immunization administration through 18 years; first component
90461	Immunization administration; each additional vaccine
90472	Immunization administration; each additional vaccine (route injection)
90473	Immunization administration by intranasal/oral; 1 vaccine
90474	Immunization administration by intranasal/oral; each additional vaccine

Authorization, Documentation, and Claim Requirements

Prior Authorization

Prior authorization for certain surgical treatments

Table 6 lists surgical treatment and anesthesia CPT/HCPCS codes that require prior authorization before EFP coverage will be approved. Examples include anesthesia for vaginal procedures (00940, 00942, 00944, 00950, 00952), implantable contraceptive insert/remove codes (11981, 11982, 11983), and numerous vulvar/vaginal/uterine/adnexal surgical codes (e.g., 56405, 56605, 57170, 58100, 58999) — Table 6 contains many additional surgical CPTs that also require prior authorization.

00940, 00942, 00944, 00950, 00952 (anesthesia for vaginal procedures)
11981, 11982, 11983 (insert/remove non-biodegradable drug delivery implant)
56405, 56605, 57170, 58100, 58999 (examples of surgical procedure codes listed in Table 6)
Table 6 includes many additional surgical CPTs and anesthesia codes that require prior authorization

Documentation Required

Medical necessity and eligibility verification

Providers must verify member eligibility, coverage, and authorization criteria and submit documentation to support medical necessity. Neighborhood may apply NCDs, LCDs, EOHHS recommendations, InterQual, and Clinical Medical Policies when determining medical necessity.

Verify eligibility, coverage, and any required authorizations prior to rendering services
Neighborhood may use NCDs, LCDs, EOHHS recommendations, InterQual, and Clinical Medical Policies to determine medical necessity

Billing Rule

Coding and claim submission standards

Claims must follow AMA CPT, ICD-10-CM, and HCPCS Level II coding and be submitted within contractually determined timely filing guidelines; adjustments, corrections, and reconsiderations must include the required forms and comply with national claims standards.

Use CPT, ICD-10-CM, and HCPCS Level II codes as defined by national coding authorities
Submit complete claims within contractual timely filing guidelines
Adjustments/corrections/reconsiderations require the required forms and compliance with national claim standards

Clinical and Program Background

Extended Family Planning (EFP) is a limited Medicaid benefit in Rhode Island available to eligible female RIte Care members who meet program requirements (members above the Federal Poverty Level and those who are postpartum or at least 60 days post pregnancy loss). Services provided under EFP must be medically necessary; Neighborhood may apply NCDs, LCDs EOHHS recommendations, InterQual, and Clinical Medical Policies when determining necessity and providers are responsible for verifying eligibility and authorization criteria prior to rendering services.

The EFP benefit covers a defined set of family planning services, including a one annual gynecologic exam per rolling 12‑month period (with a one‑month grace period, effectively allowing 11 months between exams), contraceptive services and counseling, select STI testing and treatment, repeat Pap/colposcopy when related to family planning visits, sterilization, selected laboratory and cytology tests, surgical treatment (including anesthesia) for major complications arising from family planning procedures, interpreter/sign language services, and state‑supplied immunizations and their administration.

EFP does not cover services outside the CMS‑approved EFP service list; non‑formulary drugs and transportation are excluded. Claims must follow AMA CPT, ICD‑10‑CM, and HCPCS coding and be submitted within contractual timely‑filing guidelines, and all billed services must be supported by documentation demonstrating medical necessity.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyExtended Family Planning (EFP) coverage and reimbursement requirements

Policy CodePolicy N/A

Change TypeClarified (non-material)

Effective DateJul 1, 2019

Next Review Date

Key ActionVerify member eligibility, confirm coverage and prior authorization requirements (especially for surgical codes listed in Table 6), and submit documentation to support medical necessity.

SourceLink

On This Page

OpenPayer

Extended Family Planning (EFP) coverage and reimbursement requirements

Extended Family Planning (EFP) Coverage Conditions

Relevant Procedure, Diagnosis, and Other Codes

Authorization, Documentation, and Claim Requirements

Clinical and Program Background

Defined Terms

Policy Changes and Review History

At-a-Glance Policy Metrics