Neighborhood Health Plan RI EFP Coverage & Prior Auth

Covered Services & Eligibility

Covered EFP Services

Covered when services are medically necessary and the member meets EFP eligibility:

EFP member eligibility: Member is a RIte Care member above the Federal Poverty Level, qualified for RIte Care, was pregnant and is now within 12 months postpartum or within 12 months since a pregnancy loss, and is at risk of losing Medicaid eligibility.12 months

From policy eligibility section

Service types covered: One (1) gynecological annual exam per rolling year (with a one-month grace period / 11 months between), including Pap; family planning related visits; colposcopy; repeat Pap as follow-up to an abnormal Pap performed as part of a routine/periodic family planning visit; sterilization; some laboratory tests; surgical treatment (including anesthesia) of major complications arising from a family planning procedure; 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; and state‑supplied vaccinations and their administration.1 per rolling year

See Medical Coverage table list

Pharmacy coverage: Allowable pharmaceuticals must be listed on the Neighborhood formulary. Drugs for treatment of STIs/SDTs (except HIV/AIDS and hepatitis) identified during a routine/periodic family planning visit, and drugs for treatment of vaginal, lower genital tract or genital skin infections and urinary tract infections identified during a routine/periodic family planning visit, may be covered.formulary inclusion

See Pharmacy Coverage

EFP does not cover services that fall outside the CMS‑approved list of EFP services or that are not specifically listed in this policy. Transportation is explicitly excluded from the EFP benefit package. Additionally, non‑formulary drugs will not be covered; pharmaceuticals must be on the Neighborhood formulary to be payable under EFP.

This payment policy is informational only and is not a guarantee of reimbursement. Coverage and payment are subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. The policy may be updated at any time and billed services remain subject to audit.

All services must be medically necessary to qualify for reimbursement. Neighborhood may apply National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry‑accepted criteria such as Interqual, guidance from the Rhode Island Executive Office of Health and Human Services (EOHHS), and Neighborhood Clinical Medical Policies when determining medical necessity. Services not meeting medical necessity criteria or those outside the CMS‑approved EFP list may be denied.

Diagnosis, Procedure, and Administration Codes

Diagnosis codes for EFP Annual ExamsICD-10Covered

Z01.411	Encounter for gynecological exam (general) (routine) with abnormal findings
Z01.419	Encounter for gynecological exam (general) (routine) without abnormal findings

Diagnosis codes source (document)ICD-10

No codes listed

Table 1 & Table 2 service CPT/HCPCS codes (Annual exam, family planning visits, device services)mixedCovered

99394	Periodic comprehensive preventive medicine reevaluation and management; adolescent (12-17)
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
99202	Office or outpatient visit, new patient, expanded problem focused
99203	Office or outpatient visit, new patient, detailed history/exam
99204	Office or outpatient visit, new patient, comprehensive
99205	Office or outpatient visit, new patient, high complexity
99211	Office visit, established patient, minimal

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Diagnosis code for EFP SterilizationICD-10Covered

Z30.2

Encounter for sterilization

Table 3 sterilization procedure and anesthesia codesCPTCovered

00851	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection
58565	Hysteroscopy with bilateral fallopian tube cannulation with permanent implants
58600	Ligation or transection of fallopian tube(s)
58611	Ligation or transection of fallopian tube(s) at time of cesarean or 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

Table 4 & Table 5 laboratory and pathology codesCPTCovered

81000	Urinalysis, dip stick or tablet reagent; non-automated, with microscopy
81002	Urinalysis, dip stick or tablet reagent; non-automated, without microscopy
81003	Urinalysis, automated, 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	Blood count; hematocrit (Hct)

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Table 6 anesthesia and implant procedure codes (require prior auth)CPTCovered

00940	Anesthesia for vaginal procedures; NOS
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, colporrhaphy
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

Table 2 codesCPT

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 7 - Interpreter ServicesHCPCSCovered

T1013

Sign language or oral interpretive services, per 15 minutes

Table 8 - Immunization administrationCPT

90460	Immunization administration through 18 years; first or only component
90461	Immunization administration through 18 years; each additional component
90471	Immunization administration; 1 vaccine (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

Female genital procedures and interpreter serviceCPT|HCPCS

58999	Unlisted procedure, female genital system (nonobstetrical)
59100	Hysterotomy, abdominal (eg, for hydatidiform mole, abortion)
59120	Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach
59121	Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy
59130	Surgical treatment of ectopic pregnancy; abdominal pregnancy
59135	Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy
59136	Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus
59140	Surgical treatment of ectopic pregnancy; cervical, with evacuation
59150	Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy
59870	Uterine evacuation and curettage for hydatidiform mole

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Immunization administration CPT codesCPT

90460	Immunization administration through 18 years of age via any route; first or only component
90461	Immunization administration through 18 years of age via any route; each additional component
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

Minimum interval11 months between exams (with a one-month grace period)

IncludesExam includes a Pap test when performed as part of the annual GYN exam

Authorization, Billing & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain surgical procedures and associated anesthesia listed in Table 6 and Table 6/36 (see service codes). Providers must verify and obtain prior authorization via Neighborhood's plan-specific Prior Authorization Reference page before scheduling or performing these procedures.

See Table 6 and Table 6/36 for affected anesthesia and surgical CPT/HCPCS codes (e.g., 00940, 00942, 00944, 00950, 00952, 11981-11983, 56405-56501, 58999, 59100-59150, 59870).
Prior authorization required prior to claim submission when these procedures are billed.

Denial Risk

Denial Triggers

Services that are not medically necessary, services outside the CMS-approved EFP list, services for non-formulary drugs, or services lacking required prior authorization are subject to denial. Failure to meet coding, documentation, or timely filing requirements may also result in claim denials.

Policy Background

Extended Family Planning (EFP) provides a limited set of family‑planning and related services to eligible RIte Care members who were recently pregnant or experienced a pregnancy loss and are at risk of losing Medicaid eligibility. Covered services include one gynecologic annual exam per rolling year (with Pap), family planning visits and counseling, sterilization, select laboratory and pathology tests, STI testing and treatment drugs when indicated during a family planning visit, FDA‑approved contraceptive methods and management, interpreter services (see Table 7), and certain state‑supplied immunizations and administration (see Table 8). Members meeting the 12‑month eligibility window postpartum or post‑pregnancy loss and otherwise qualifying for EFP may receive these services without member cost sharing as described in the policy.

Key Definitions & Eligibility

EFP eligibility window

Eligibility windowMembers who were pregnant are eligible up to 12 months postpartum or up to 12 months after pregnancy loss

PopulationMust have qualified for RIte Care and be above the Federal Poverty Level

PurposeFor members who are at risk of losing Medicaid eligibility (EFP program)

T1013 — Interpreter services

CodeT1013

DescriptionSign language or oral interpretive services, billed per 15 minutes

Usage note

OpenPayer

Extended Family Planning (EFP) — Coverage, Coding, and Reimbursement

Covered Services & Eligibility

Diagnosis, Procedure, and Administration Codes

Authorization, Billing & Documentation Requirements

Policy Background

Key Definitions & Eligibility