Washington Apple Health (Medicaid)
Family Planning
Billing Guide
Including:
Reproductive Health Services, Family Planning
Only Pregnancy Related program and Family
Planning Only program
January 1, 2023
CPT® codes and descriptions only are copyright 2022 American Medical Association.
2 | Family Planning Billing Guide
Disclaimer
Every effort has been made to ensure this guide’s accuracy. If an actual or
apparent conflict between this document and a Health Care Authority (HCA) rule
arises, the HCA rule applies.
Billing guides are updated on a regular basis. Due to the nature of content
change on the internet, we do not fix broken links in past guides. If you find a
broken link, please check the most recent version of the guide. If this is the most
recent guide, please notify us at askmedic[email protected].gov.
About this guide
1
This publication takes effect January 1, 2023, and supersedes earlier billing
guides to this program.
This billing guide includes billing information for the following programs:
Reproductive Health Services
Family Planning Only Pregnancy Related
Family Planning Only
HCA is committed to providing equal access to our services. If you need an
accommodation or require documents in another format, please call 1-800-562-
3022. People who have hearing or speech disabilities, please call 711 for relay
services.
Washington Apple Health means the public health insurance
programs for eligible Washington residents. Washington Apple
Health is the name used in Washington State for Medicaid, the
children’s health insurance program (CHIP), and state-only
funded health care programs. Washington Apple Health is
administered by HCA.
Refer also to HCA’s ProviderOne Billing and Resource Guide for valuable
information to help you conduct business with HCA.
How can I get HCA Apple Health provider documents?
To access providers alerts, go to HCA’s provider alerts webpage.
To access provider documents, go to HCA’s provider billing guides and fee
schedules webpage.
1
This publication is a billing instruction.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
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Confidentiality toolkit for providers
The Washington State Confidentiality Toolkit for Providers is a resource for
providers required to comply with health care privacy laws. To learn more about
the toolkit, visit the HCA website.
Where can I download HCA forms?
To download an HCA form, see HCA’s Forms & Publications webpage. Type only
the form number into the Search box (Example: 13-835).
Copyright disclosure
Current Procedural Terminology (CPT) copyright 2022 American Medical
Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Fee schedules, relative value units, conversion factors and/or related components
are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
What has changed?
The table below briefly outlines how this publication differs from the previous
one. This table is organized by subject matter. Each item in the Subject column is
a hyperlink that, when clicked, will take you to the specific change summarized in
that row of the table.
Subject Change Reason for Change
Confidentiality toolkit for
providers
Added new resource
for health care
providers required to
comply with health
care privacy laws
New resource
How do I verify a client’s
eligibility
Created note box
with updated ways
to apply for Apple
Health coverage
To keep information
current
Integrated Apple Health
Foster Care (AHFC)
Revised age of
clients in foster care
(out of home
placement) from 21
to 18
To distinguish these
clients from those ages
18-21 who are in
extended foster care
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Subject Change Reason for Change
How do providers who
participate in the 340B
drug pricing program bill
for drugs and dispensing
fees?
Added language to
expressly state that
the provider must be
enrolled and
participating in the
340B Drug Pricing
Program to receive
the dispensing fee
Clarification, not a policy
change. It has always
been true that non-340B
providers are ineligible
for dispensing fees.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
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Table of Contents
Resources Available .......................................................................................................................... 8
Definitions ............................................................................................................................................ 9
Client Eligibility................................................................................................................................ 11
How do I verify a client’s eligibility? ................................................................................. 11
Verifying eligibility is a two-step process: ................................................................. 11
Are clients enrolled in an HCA-contracted managed care organization (MCO)
eligible? .......................................................................................................................................... 11
Managed care enrollment ................................................................................................. 12
Clients who are not enrolled in an HCA-contracted managed care plan for
physical health services ...................................................................................................... 13
Integrated managed care .................................................................................................. 13
Integrated Apple Health Foster Care (AHFC) ........................................................... 14
Fee-for-service Apple Health Foster Care .................................................................. 14
American Indian/Alaska Native (AI/AN) Clients ..................................................... 14
Provider Requirements ................................................................................................................ 15
Confidentiality, consent, and release of information ................................................ 15
Nationally recognized clinical guidelines ....................................................................... 15
How do I bill claims electronically? ................................................................................... 16
How do providers bill for managed care services? .................................................... 16
How do providers who participate in the 340B drug pricing program bill for
drugs and dispensing fees? ................................................................................................... 17
Sexual and Reproductive Health Program (SRHP) Fee Schedule ............................. 18
SRHP fee schedule requirements ....................................................................................... 18
Federally Qualified Health Center (FQHC) SRHP Billing ...................................... 18
Reproductive Health Services ................................................................................................... 19
What are reproductive health services? .......................................................................... 19
Who is eligible for reproductive health services? ....................................................... 19
Managed care clients .......................................................................................................... 19
Self-referral for managed care clients ......................................................................... 19
Limited coverage ................................................................................................................... 20
Where can Washington Apple Health clients receive reproductive health
services? ......................................................................................................................................... 20
What are the requirements for providers? ..................................................................... 20
What reproductive health services are covered? ........................................................ 21
What reproductive health services are not covered? ................................................ 22
What fee does HCA pay? ........................................................................................................ 22
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Family Planning Only Programs .............................................................................................. 23
What is the purpose of the Family Planning Only programs? .............................. 23
Who is eligible?........................................................................................................................... 23
Family Planning Only Pregnancy Related program ........................................... 23
Family Planning Only program ....................................................................................... 23
What services are covered under the Family Planning Only programs? .......... 25
Complications from contraceptive methods ............................................................ 26
What drugs and supplies are covered under the Family Planning Only
programs? ..................................................................................................................................... 27
Coverage table ............................................................................................................................ 27
Office visits for family planning surveillance and follow-up visits ................. 28
Comprehensive prevention family planning visit ................................................... 28
Contraceptives ........................................................................................................................ 29
Radiology services ................................................................................................................ 29
Human papillomavirus (HPV) immunization ............................................................ 29
Laboratory services .............................................................................................................. 30
STD/STI treatment ................................................................................................................ 32
What does HCA pay for? ........................................................................................................ 33
What fee does HCA pay? ........................................................................................................ 33
What does HCA not pay for? ................................................................................................ 33
Billing for third-party liability and “good cause” ........................................................ 34
What are the requirements for Family Planning Only programs providers? . 35
Documentation requirements ......................................................................................... 35
Provider requirements specific to the Family Planning Only program ........ 35
What contraceptives does HCA cover? ............................................................................ 36
Hormonal contraceptive prescribing ........................................................................... 36
Hormonal contraceptives filled at the pharmacy ................................................... 38
Hormonal contraceptives dispensed from a family planning clinic .............. 38
Immediate postpartum Long-Acting Reversible Contraceptive (LARC)
insertion .................................................................................................................................... 39
Contraceptives coverage table ............................................................................................ 39
Prescription contraceptives .............................................................................................. 39
Nonprescription over-the-counter (OTC) contraceptives .................................. 43
Nondrug contraceptive supplies (natural family planning) .............................. 44
Appendix A ........................................................................................................................................ 45
Clinic visit scenarios for Family Planning Only programs ....................................... 45
Appendix B ........................................................................................................................................ 47
CPT® codes and descriptions only are copyright 2022 American Medical Association.
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Frequently asked questions .................................................................................................. 47
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Resources Available
Topic Resource
Information about reproductive
health services, the Family Planning
Only and Family Planning Only
Pregnancy Related programs
Contact the Billers, providers, and partners “Contact
us” webpage.
Contact the Family Planning Program at:
familyplanning@hca.wa.gov.
For additional billing guidance See the following billing guides:
Outpatient Hospital Billing Guide
Physician-Related/Professional Services Billing
Guide
Professional Administered Drugs Fee Schedule
Family Planning Only application
form, HCA 13-781 (8/20) (for
clients)
See Where can I download HCA forms?
Information about sterilization See HCA’s Sterilization Supplement Billing Guide and
WAC 182-531-1550.
Pharmacy information See HCA’s Pharmacy Information and the Prescription
Drug Program Billing Guide.
Additional HCA resources See HCA’s Billers, providers, and partners webpage.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
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Definitions
This section defines terms and abbreviations, including acronyms, used in this
billing guide. Refer to chapter 182-500 WAC for a complete list of definitions for
Washington Apple Health.
340B dispensing feeHCA’S established fee paid to a registered and Medicaid-
participating 340B drug program provider under the public health service (PHS)
act for expenses involved in acquiring, storing and dispensing prescription drugs
or drug-containing devices (see WAC 182-530-7900). A dispensing fee is not paid
for nondrug items, devices, or supplies (see WAC 182-530-7050).
Applicant A person applying for Family Planning Only services.
Comprehensive preventive family planning visitA comprehensive,
preventive, contraceptive visit that includes evaluation and management of an
individual, such as: age-appropriate history, examination, counseling/anticipatory
guidance, risk factor reduction interventions, and laboratory and diagnostic
procedures that are covered under the client’s respective HCA program.
ContraceptionPrevention of pregnancy using contraceptive methods.
Contraceptive Food and Drug Administration (FDA)-approved prescription and
nonprescription methods, including devices, drugs, products, methods, or
surgical interventions used to prevent pregnancy, as described in WAC 182-530-
2000.
Family planning clinicA clinic that is designated by HCA to provide family
planning services to eligible people as described in this guide. Other types of
providers may offer family planning services within their scope of practice.
Family Planning Only program - The program that covers family planning only
services for eligible clients for 12 months from the date HCA determines
eligibility.
Family Planning OnlyPregnancy Related programThe program that
covers family planning only services for eligible clients for 10 months following
the 60-day post pregnancy period.
Family planning servicesMedically safe and effective medical care,
educational services, and contraceptives that enable individuals to plan and space
the number of children they have and avoid unintended pregnancies.
Informed consent When an individual consents to a procedure after the
provider who obtained a properly completed consent form has done all of the
following:
Disclosed and discussed the client’s diagnosis
Offered the client an opportunity to ask questions about the procedure and
request information in writing
Given the client a copy of the consent form
Communicated effectively using any language interpretation or special
communication device necessary per 42 CFR 441.257
Given the client oral information about all the following:
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o The client’s right to not obtain the procedure, including potential risks,
benefits, and the consequences of not obtaining the procedure
o Alternatives to the procedure including potential risks, benefits, and
consequences
o The procedure itself, including potential risks, benefits, and consequences
(WAC 182-531-0050)
Natural family planning (also known as fertility awareness method) Methods
to identify the fertile days of the menstrual cycle and avoid unintended
pregnancies, such as observing, recording, and interpreting the natural signs and
symptoms associated with the menstrual cycle.
Over-the-counter (OTC) Drugs, devices, and products that do not require a
prescription to be sold or dispensed (see WAC 182-531-0050).
Public Health Service Act (PHS) The federal act governing the 340B program
administered through the Office of Pharmacy Affairs. Per Washington
Administrative Code (WAC), any drugs or items purchased through this program
must be billed at the actual acquisition cost (see WAC 182-530-7900).
Reproductive health - The prevention and treatment of illness, disease, and
disability related to the function of reproductive systems during all stages of life,
and includes:
Related, appropriate, and medically necessary care
Education of clients in medically safe and effective methods of family planning
Pregnancy and reproductive health care
Reproductive health care services - Any medical services or treatments,
including pharmaceutical and preventive care services or treatments, directly
involved in the reproductive system and its processes, functions, and organs
involved in reproduction, in all stages of life. Reproductive health care services do
not include infertility treatment.
Reproductive system - Includes, but is not limited to: Genitals, gonads, the
uterus, ovaries, fallopian tubes, and breasts.
Sexually Transmitted Infection (STI)A disease or infection acquired as a result
of sexual contact.
U.S. Citizenship and Immigration Services (USCIS)Refer to USCIS for a
definition.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
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Client Eligibility
Most Apple Health clients are enrolled in an HCA-contracted managed care
organization (MCO). This means that Apple Health pays a monthly premium to an
MCO for providing preventative, primary, specialty, and other health services to
Apple Health clients. Clients in managed care must see only providers who are in
their MCO’s provider network, unless prior authorized or to treat urgent or
emergent care. See HCA’s Apple Health managed care page for further details.
It is important to always check a client’s eligibility prior to
providing any services because it affects who will pay for the
services.
How do I verify a client’s eligibility?
Check the client’s services card or follow the two-step process below to verify
that a client has Apple Health coverage for the date of service and that the
client’s benefit package covers the applicable service. This helps prevent
delivering a service HCA will not pay for.
Verifying eligibility is a two-step process:
Step 1. Verify the patient’s eligibility for Apple Health. For detailed
instructions on verifying a patient’s eligibility for Apple Health,
see the Client Eligibility, Benefit Packages, and Coverage Limits
section in HCA’s ProviderOne Billing and Resource Guide.
If the patient is eligible for Apple Health, proceed to Step 2. If
the patient is not eligible, see the note box below.
Step 2. Verify service coverage under the Apple Health client’s
benefit package. To determine if the requested service is a
covered benefit under the Apple Health client’s benefit package,
see HCA’s Program Benefit Packages and Scope of Services
webpage.
Note: Patients who are not Apple Health clients may apply for
health care coverage in one of the following ways:
Online: Go to Washington Healthplanfinder - select
the "Apply Now" button. For patients age 65 and older or on
Medicare, go to Washington Connections select the “Apply
Now” button.
Mobile app: Download the WAPlanfinder appselect “sign
in” or “create an account”.
Phone: Call the Washington Healthplanfinder Customer
Support Center at 1-855-923-4633 or 855-627-9604 (TTY).
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Paper: By completing an Application for Health Care
Coverage (HCA 18-001P) form.
To download an HCA form, see HCA’s Free or Low Cost
Health Care, Forms & Publications webpage. Type only the
form number into the Search box (Example: 18-001P). For
patients age 65 and older or on Medicare, complete the
Washington Apple Health Application for Aged, Blind,
Disabled/Long-Term Services and Support (HCA 18-005) form.
In-person: Local resources who, at no additional cost, can
help you apply for health coverage. See the Health Benefit
Exchange Navigator.
Are clients enrolled in an HCA-contracted managed
care organization (MCO) eligible?
Yes. Most Apple Health (Medicaid) clients are enrolled in one of HCA’s contracted
managed care organizations (MCOs). For these clients, managed care enrollment
is displayed on the client benefit inquiry screen in ProviderOne.
All medical services covered under an HCA-contracted MCO must be obtained
through the MCO’s contracted network. The MCO is responsible for:
Payment of covered services
Payment of services referred by a provider participating with the plan to an
outside provider
Note: A client’s enrollment can change monthly. Providers who
are not contracted with the MCO must receive approval from
both the MCO and the client’s primary care provider (PCP) prior
to serving a managed care client.
Send claims to the client’s MCO for payment. Call the client’s MCO to discuss
payment prior to providing the service. Providers may bill clients only in very
limited situations as described in WAC 182-502-0160.
Managed care enrollment
Most Apple Health (Medicaid) clients are enrolled in HCA-contracted MCO the
same month they are determined eligible for managed care as a new or renewing
client. Some clients may still start their first month of eligibility in the FFS
program because their qualification for MC enrollment is not established until the
month following their Medicaid eligibility determination. Providers must check
eligibility to determine enrollment for the month of service.
New clients are those initially applying for benefits or those with changes in their
existing eligibility program that consequently make them eligible for Apple
Health managed care.
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Checking eligibility
Providers must check eligibility and know when a client is enrolled and with
which MCO. For help with enrolling, clients can refer to the Washington
Healthplanfinder’s Get Help Enrolling page.
MCOs have retroactive authorization and notification policies in place. The
provider must know the MCO’s requirements and be compliant with the
MCO’s policies.
Clients have a variety of options to change their plan:
Available to clients with a Washington Healthplanfinder account:
Go to Washington Healthplanfinder website.
Available to all Apple Health clients:
o Visit the ProviderOne Client Portal website:
o Request a change online at ProviderOne Contact Us (this will generate
an email to Apple Health Customer Service). Select the topic
“Enroll/Change Health Plans.”
o Call Apple Health Customer Service at 1-800-562-3022. The automated
system is available 24/7.
For online information, direct clients to HCA’s Apple Health Managed Care
webpage.
Clients who are not enrolled in an HCA-contracted
managed care plan for physical health services
Some Medicaid clients do not meet the qualifications for managed care
enrollment. These clients are eligible for services under the FFS Medicaid
program. In this situation, each Integrated Managed Care (IMC) plan will have
Behavioral Health Services Only (BHSO) plans available for Apple Health clients
who are not in managed care. The BHSO covers only behavioral health treatment
for those clients. Eligible clients who are not enrolled in an HCA-contracted
managed care plan are automatically enrolled in a BHSO except for American
Indian/Alaska Native clients. If the client receives Medicaid-covered services
before being automatically enrolled in a BHSO, the FFS Medicaid program will
reimburse providers for the covered services. Some examples of populations that
may be exempt from enrolling into a managed care plan are Medicare dual-
eligible, American Indian/Alaska Native, Adoption support and Foster Care
alumni.
Integrated managed care
Clients qualified for enrollment in an integrated managed care plan receive all
physical health services, mental health services, and substance use disorder
treatment through their HCA-contracted managed care organization (MCO).
For full details on integrated managed care, see HCA’s Apple Health managed
care webpage and scroll down to “Changes to Apple Health managed care.”
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Integrated Apple Health Foster Care (AHFC)
Children and young adults in the Foster Care, Adoption Support and Alumni
programs who are enrolled in Coordinated Care of Washington’s (CCW) Apple
Health Foster Care program receive both medical and behavioral health services
from CCW.
Clients under this program are:
Under the age of 18 who are in foster care (out of home placement)
Under the age of 21 who are receiving adoption support
Age 18-21 years old in extended foster care
Age 18 to 26 years old who aged out of foster care on or after their 18th
birthday (alumni)
These clients are identified in ProviderOne as “Coordinated Care
Healthy Options Foster Care.”
The Apple Health Customer Services staff can answer general questions about
this program. For specific questions about Adoption Support, Foster Care or
Alumni clients, contact HCA’s Foster Care and Adoption Support Team at 1-800-
562-3022, Ext. 15480.
Fee-for-service Apple Health Foster Care
Children and young adults in the fee-for-service Apple Health Foster Care,
Adoption Support and Alumni programs receive behavioral health services
through the regional Behavioral Health Services Organization (BHSO). For details,
see HCA’s Mental Health Services Billing Guide, under How do providers identify
the correct payer?
American Indian/Alaska Native (AI/AN) Clients
American Indian/Alaska Native (AI/AN) clients have two options for Apple
Health coverage:
Apple Health Managed Care
Apple Health coverage without a managed care plan (also referred to as fee-
for-service [FFS])
If an AI/AN client does not choose a managed care plan, they will be
automatically enrolled into Apple Health FFS for all their health care services,
including comprehensive behavioral health services. See the Health Care
Authority’s (HCA) American Indian/Alaska Native webpage.
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Provider Requirements
Confidentiality, consent, and release of information
When providing family planning services, providers must do all the following:
Follow federal Health Insurance Portability and Accountability Act (HIPAA)
requirements in safeguarding the confidentiality of clients’ records. These
safeguards must do the following:
o Allow for timely sharing of information with appropriate professionals
and agencies on the client’s behalf
o Ensure that confidentiality of disseminated information is protected
(See chapter 70.02 RCW for more details.)
Ensure that all necessary forms are accurately and fully completed:
o Informed consent as defined in WAC 182-531-0050 and as required by
WAC 182-531-1550, as necessary
o The federal Consent for Sterilization form HHS-687 must be attached to
a sterilization claim. See the Sterilization Supplemental Billing Guide for
requirements and instructions. See also Where can I download HCA
forms?
o Authorization from clients for release of information
Ensure the proper release of client information:
o To transfer information to another provider when a client changes
providers or when the provider is unable to provide services (in a timely
manner)
o To transfer information to a primary care provider when a client needs
non-family planning related services
o To conform to all applicable state and federal laws
Nationally recognized clinical guidelines
Providers must follow nationally recognized clinical guidelines. Cervical cancer
screening guidelines are produced by the American Society for Colposcopy and
Cervical Pathology (ASCCP), the American College of Obstetrics and Gynecology
(ACOG), the American Cancer Society (ACS), and the U.S. Preventive Services Task
Force (USPSTF). Breast cancer screening guidelines are produced by the American
College of Obstetrics and Gynecology (ACOG), the American Cancer Society
(ACS), and the U.S. Preventive Services Task Force (USPSTF). Family planning
guidelines are produced by the Centers for Disease Control and Prevention (CDC)
and the U.S. Office of Population Affairs.
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How do I bill claims electronically?
All claims must be submitted electronically to HCA, except under
limited circumstances. For more information about this policy
change, see Paperless Billing at HCA. For providers approved to
bill paper claims, see HCA’s Paper Claim Billing Resource.
Instructions on how to bill Direct Data Entry (DDE) claims can be found on HCAs
Billers, providers, and partners webpage.
For information about billing Health Insurance Portability and Accountability Act
(HIPAA) Electronic Data Interchange (EDI) claims, see the ProviderOne 5010
companion guides on the HIPAA Electronic Data Interchange (EDI) webpage.
How do providers bill for managed care services?
Family planning providers under contract with an HCA-contracted managed care
organization (MCO) must directly bill the MCO for family planning or sexually
transmitted infection (STI) services received by clients enrolled in the MCO.
Family planning providers not under contract with an HCA-contracted MCO must
bill using fee-for-service when providing services to managed care clients who
self-refer outside their plans.
Family planning providers or HCA-contracted local health department STI clinics
who are contracted with an HCA-contracted managed care organization (MCO)
must follow their contract regarding laboratory services for MCO clients.
Family planning providers or HCA-contracted local health department STI clinics
not under contract with an HCA-contracted MCO must pay a laboratory directly
for services provided to clients who self-refer outside of their MCO. Providers
then must bill HCA for payment for laboratory services.
Laboratories must be certified through the Clinical Laboratory Improvements
Act (CLIA).
Documentation of current CLIA certification must be kept on file.
Send claims to the client’s MCO for payment. Call the client’s MCO to discuss
payment before providing the service. Providers may bill clients only in very
limited situations as described in WAC 182-502-0160.
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How do providers who participate in the 340B drug
pricing program bill for drugs and dispensing fees?
Bill HCA the actual acquisition cost (AAC) for all drugs purchased under the 340B
Drug Pricing Program.
The provider NPI used for 340B drugs must be listed on the federal Office of
Pharmacy Affairs Medicaid Exclusion File. To receive the 340B dispensing fee, the
provider must be enrolled and participating in the 340B Drug Pricing Program
and listed on the Medicaid Exclusion file as a 318-entity type (STD clinic). HCA
pays the 340B dispensing fee only for HCA-designated hormonal contraceptives
that are purchased through the 340B program of the Public Health Service Act.
(See chapter 182-530 WAC.)
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Sexual and Reproductive Health Program
(SRHP) Fee Schedule
Effective October 1, 2021, Apple Health pays an enhanced rate to contracted
providers in the Department of Health’s (DOH) SRHP for designated procedure
codes. Refer to the SRHP fee schedule. For information on how to enroll in the
SRHP, visit the Department of Health website. SRHP was formerly known as the
Washington Title X Family Planning Program.
Note: SRHP fee schedule rates are payable only to billing
provider NPIs for SRHP contracted providers. It is the
responsibility of each SRHP-contracted provider to ensure Apple
Health has a complete, updated list of billing provider NPIs. If
you are an SRHP contracted provider, please contact
familyplanning@hca.wa.gov to verify or update your billing
provider NPIs. HCA will verify current SRHP contract status with
DOH. If HCA does not have the billing providers NPIs identified
in the ProviderOne system, HCA will pay at the regular fee
schedule rates.
SRHP fee schedule requirements
To be paid, SRHP contracted providers must bill using the KX modifier according
to the SRHP fee schedule.
Clients with Family Planning Only medical coverage are not eligible for all service
codes on the SRHP fee schedule. Refer to What services are covered under the
Family Planning Only programs?
SRHP contracted providers are eligible for the SRHP fee schedule rates even
when the care provided is not related to family planning. For example, an SRHP
contracted provider may bill an E/M code with the KX modifier for a visit focused
on gender-affirming care.
Federally Qualified Health Center (FQHC) SRHP Billing
FQHCs providing SRHP services do not receive the enhanced SRHP fee schedule
rates and must not bill with the KX modifier on the same day an FQHC encounter
eligible service is performed. SRHP services performed on the same day as an
eligible encounter must be bundled with the encounter.
For FQHC SRHP services that are not performed on the same day as an encounter
eligible service, FQHCs must bill with the KX modifier to receive the enhanced
rate. This FQHC SRHP billing guidance applies to both fee-for-service and
managed care claims.
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Reproductive Health Services
What are reproductive health services?
HCA defines reproductive health services as those services that:
Assist clients in avoiding illness, disease, and disability related to reproductive
health.
Provide related, appropriate, and medically necessary care when needed.
Assist clients in making informed decisions about using medically safe and
effective methods of family planning.
Who is eligible for reproductive health services?
HCA covers medically necessary reproductive health services, as described in this
guide, for clients covered by one of the Washington Apple Health programs as
listed in the table in WAC 182-501-0060.
Managed care clients
For clients enrolled in one of the HCA-contracted managed care organizations
(MCOs), managed care enrollment will be displayed on the client benefit inquiry
screen in ProviderOne.
Clients enrolled in an HCA-contracted MCO must obtain services through their
MCO, unless otherwise noted.
Note: A client’s enrollment can change monthly. Providers who
are not contracted with the MCO must receive approval from
both the MCO and the client’s primary care provider (PCP) prior
to serving a managed care client.
Self-referral for managed care clients
A client enrolled in an HCA-contracted MCO may self-refer outside their MCO for
reproductive health care services including, but not limited to:
Family planning
Abortion
Sexually transmitted infection (STI) services
A client may seek services from any HCA-approved provider. A client who is age
21 or older may not self-refer outside their MCO for sterilization.
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Limited coverage
Family Planning Only programs
Family Planning Only Pregnancy Related and Family Planning Only clients are
eligible to receive limited reproductive health services which includes only family
planning and specified family planning-related services. See the program
guidelines in this guide.
Alien Emergency Medical
Under WAC 182-507-0115, HCA covers reproductive health services under Alien
Emergency Medical programs only when the services are directly related to an
emergency medical condition.
Where can Washington Apple Health clients receive
reproductive health services?
Reproductive health services can be provided by any licensed, HCA-contracted
provider whose scope of practice includes reproductive health or the ancillary
services associated with a reproductive health procedure or treatment (e.g.,
pathology, anesthesia, facility, etc.). See chapter 182-502 WAC for requirements
of HCA-contracted providers.
What are the requirements for providers?
To be paid by HCA for reproductive health services provided to eligible clients,
providers, including licensed midwives, must:
Meet the requirements in chapters 182-501, 182-502, and 182-532 WAC.
Provide only those services that are within the scope of their licenses.
Bill HCA according to this guide and other applicable HCA billing guides.
Educate clients on Food and Drug Administration (FDA)-approved
contraceptive methods and over-the-counter (OTC) contraceptive drugs,
devices, and products, as well as related medical services.
Provide medical services related to FDA-approved contraceptive methods and
OTC contraceptive drugs, devices, and products upon request.
Supply or prescribe FDA-approved contraceptive methods and OTC
contraceptive drugs, devices, and products upon request.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
21 | Family Planning Billing Guide
What reproductive health services are covered?
In addition to the services listed in WAC 182-531-0100, HCA covers all the
following reproductive health services:
For a client capable of reproducing, one comprehensive preventive family
planning visit every 365 days, based on nationally recognized clinical
guidelines. This visit must have a primary focus and diagnosis of family
planning and include the following:
o Counseling
o Education
o Risk reduction
o Initiation or management of contraceptive methods
Note: Clients who are sterilized or otherwise not at risk for
pregnancy do not qualify for a comprehensive family planning
prevention visit. They do qualify for all other services.
Contraception, including all the following:
o Food and Drug Administration (FDA)-approved contraceptive methods
(see the Prescription Drug Program Billing Guide)
o Education and supplies for FDA-approved contraceptives, natural family
planning, and abstinence (see the Contraceptives Coverage Table)
o Sterilization procedures, as described in WAC 182-531-1550 and the
Sterilization Supplemental Provider Guide
Cervical, breast, and prostate cancer screenings, according to nationally
recognized clinical guidelines (see the Physician-Related Services/Healthcare
Professional Services Billing Guide)
STI screening, testing, and treatment, according to nationally recognized
clinical guidelines
Human papillomavirus (HPV) immunization, administered according to the
recommended schedule published by the Centers for Disease Control and
Prevention (CDC)
Diagnostic services, follow-up visits, imaging, and laboratory services related
to the services listed in this section
Pregnancy-related services including:
o Maternity-related services, as described under “Maternity Care and
Services” in the Physician-Related Services/Healthcare Professional
Services Billing Guide
o Abortion (see Physician-Related Services/Healthcare Professional
Services Billing Guide)
CPT® codes and descriptions only are copyright 2022 American Medical Association.
22 | Family Planning Billing Guide
What reproductive health services are not covered?
Noncovered reproductive health services are described in HCA’s Physician-
Related Services/Healthcare Professional Services Billing Guide and WACs 182-
501-0070 and 182-531-0150.
Note: HCA reviews requests for noncovered services under WAC
182-501-0160.
What fee does HCA pay?
HCA pays:
o Providers for covered reproductive health services using HCA’s Family
Planning Fee Schedule.
o For family planning pharmacy services, family planning laboratory
services, human papillomavirus (HPV) immunization, and sterilization
services using HCA’s published fee schedules.
o A dispensing fee only for contraceptive drugs purchased through the
340B program of the Public Health Service Act.
HCA requires providers to seek timely reimbursement from a third party when
a client has available third-party resources, as described under WAC 182-501-
0200. See Billing for third-party liability and “good cause for exceptions.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
23 | Family Planning Billing Guide
Family Planning Only Programs
What is the purpose of the Family Planning Only
programs?
The purpose of the Family Planning Only programs is to provide family planning
services to:
Improve access to family planning and family planning-related services.
Reduce unintended pregnancies.
Promote healthy intervals between pregnancies and births.
Who is eligible?
To be eligible for one of the Family Planning Only programs listed in this section,
a client must meet the qualifications for that program.
Family Planning Only Pregnancy Related program
To be eligible for Family Planning Only Pregnancy Related services, a client
must be determined eligible for Washington Apple Health for pregnant clients
during the pregnancy, or determined eligible for a retroactive period covering the
end of a pregnancy.
A client is automatically eligible for the Family Planning Only Pregnancy Related
program when the client’s pregnancy ends.
Note: A client may apply for the Family Planning Only program
up to 60 days before the expiration of the Family Planning Only
Pregnancy Related program. Clients will continue to use the
same Services Card they received when they applied for
pregnancy-related medical services.
Family Planning Only program
To be eligible for the Family Planning Only program, a client must meet all the
following:
Provide a valid Social Security number (SSN), unless ineligible to receive one,
or meet good cause criteria listed in WAC 182-503-0515
Be a Washington state resident, as described in WAC 182-503-0520
Have an income at or below 260% of the federal poverty level, as described in
WAC 182-505-0100
Need family planning services
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24 | Family Planning Billing Guide
Have been denied Apple Health coverage within the last 30 days, unless the
applicant meets any of the following:
o Has made an informed choice to not apply for full-scope coverage,
including family planning
o Is age 18 or younger and seeking services in confidence
o Is a domestic violence victim who is seeking services in confidence
o Has an income of 150% to 260% of the federal poverty level, as described
in WAC 182-505-0100.
A client is not eligible for Family Planning Only medical if the client is any of the
following:
Pregnant
Sterilized
Covered under another Apple Health program that includes family planning
services
Covered by concurrent creditable coverage, as defined in RCW 48.66.020,
unless the client meets any of the following:
o Is age 18 and younger and seeking services in confidence
o Is a domestic violence victim who is seeking services in confidence
o Has an income of 150% to 260% of the federal poverty level, as described
in WAC 182-505-0100.
A client may reapply for coverage under the Family Planning Only program up to
60 days before the expiration of the 12-month coverage period. HCA does not
limit the number of times a client may reapply for coverage.
Note: Always check ProviderOne to make sure that a client’s
one-year eligibility for the Family Planning Only program is still
valid, or that the client is not on another HCA program that
covers family planning services. The client must be referred to
the Washington Healthplanfinder’s website or call 1-855-
923-4633 first to determine if the client qualifies for medical
services under another program.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
25 | Family Planning Billing Guide
What services are covered under the Family Planning
Only programs?
HCA covers all the following services:
One comprehensive preventive family planning visit every 365 days, based on
nationally recognized clinical guidelines. This visit must have a primary focus
and diagnosis of family planning and include the following:
o Counseling
o Education
o Risk reduction
o Initiation or management of contraceptive methods
Assessment and management of family planning or contraceptive problems,
when medically necessary
Contraception, including all the following:
o FDA-approved contraceptive methods, as described under WAC 182-
530-2000, including, but not limited to, the following items:
Oral hormonal contraceptives (pills)
Transdermal hormonal contraceptives (patch)
Monthly intravaginal contraceptive ring
Yearly intravaginal contraceptive ring
Injectable hormonal contraceptives
Implantable hormonal contraceptives
Intrauterine devices (IUDs)
Diaphragm, cervical cap, and cervical sponge
External and internal condoms
Spermicides (foam, gel, suppositories, and cream)
Emergency contraception
o Education and supplies for FDA-approved contraceptives, natural family
planning, and abstinence
o Sterilization procedures, as described under WAC 182-531-1550.
For more details on contraceptives HCA covers, see What contraceptives does
HCA cover? and the Contraceptives Coverage Table.
The following services, when appropriate, during a visit focused on family
planning:
o Pregnancy testing
o Cervical cancer screening, according to nationally recognized clinical
guidelines
CPT® codes and descriptions only are copyright 2022 American Medical Association.
26 | Family Planning Billing Guide
o Gonorrhea and chlamydia screening and treatment for clients age 13-25,
according to nationally recognized clinical guidelines
o Syphilis screening and treatment for clients who have an increased risk
for syphilis, according to nationally recognized guidelines
o Sexually transmitted infection (STI) screening, testing, and treatment,
when medically indicated by symptoms or report of exposure, and
medically necessary for the client's safe and effective use of their chosen
contraceptive method.
Note: Pregnancy-related services, including abortions, are not
covered under the Family Planning Only programs. Refer clients
who become pregnant while on one of the Family Planning Only
programs the Washington Healthplanfinder’s website to enroll
for coverage. People may also wish to contact Within Reach for
further assistance.
Complications from contraceptive methods
HCA covers inpatient, outpatient, and professional costs when they result from a
complication arising from covered Family Planning Only programs services.
Example of a minor contraceptive complication
A client is unable to find the intrauterine device (IUD) string, it is not visualized on
the speculum exam, and an ultrasound is needed to determine its location.
Example of a serious contraceptive complication
An IUD has migrated out of the uterus and needs to be removed by laparoscopy.
For HCA to consider payment when complications occur, providers of Family
Planning Only programs-related inpatient, outpatient, or professional services
must submit to HCA a claim with a complete report of the circumstances and
conditions that caused the need for the additional services (see WAC 182-501-
0160 and WAC 182-532-540).
A complete report includes all the following:
Letter of explanation (a short description of the clinical situation and medical
necessity for the visit, procedure, testing, or surgery)
Inpatient discharge summary or outpatient chart notes
Operative report (if applicable)
Note: For information on how to submit a claim with
attachments, see the ProviderOne Resource and Billing Guide.
For complications due to a birth control method, write “birth
control complication” in the Claim Note section of the electronic
claim. Claims are subject to post-payment review.
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27 | Family Planning Billing Guide
What drugs and supplies are covered under the Family
Planning Only programs?
See the guidelines regarding contraceptive prescribing and dispensing in What
contraceptives does HCA cover?
See the Contraceptives coverage table section in this guide for contraceptive
products and procedures covered under the Family Planning Only programs.
See the Coverage table in this guide for additional procedures, drugs, and tests
covered under the Family Planning Only programs.
See the Sterilization Supplemental Billing Guide for drugs related to sterilization
procedures.
The following categories of drugs are covered:
Prescription contraceptives
Antibiotics for the treatment of chlamydia and gonorrhea
Adjunctive to a sterilization procedure
Over-the-counter, nonprescribed contraceptive drugs and supplies (for example:
emergency contraception, condoms, spermicidal foam, cream, and gel) may be
obtained through a pharmacy or a family planning clinic using a Services Card.
HCA does not pay for noncontraceptive take-home drugs dispensed at a family
planning clinic.
Coverage table
Procedures and visits are covered only if they are medically necessary for the
person’s safe and effective use of a chosen contraceptive method. See the
appropriate family planning fee schedule for fees related to covered procedures
and visits.
Note: For sterilization procedure codes, see the Sterilization
Supplemental Billing Guide. For instructions on billing for office,
professionally administered drugs, imaging, and laboratory
codes listed below, see the Physician-Related Services/Health
Care Professional Services Billing Guide. Due to its licensing
agreement with the American Medical Association, HCA
publishes only the official, short CPT® code descriptions. To view
the full descriptions, refer to a current CPT book.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
28 | Family Planning Billing Guide
Office visits for family planning surveillance and follow-up
visits
HCPCS/CPT® Code Short Description Comments
99202 Office o/p new sf 15-29
min
99203 Office o/p new low 30-
44 min
99204 Office o/p new mod 45-
59 min
99211 Office o/p est minimal
prob
99212 Office o/p est sf 10-19
min
99213 Office o/p est low 20-29
min
99214 Office o/p est mod 30-
39 min
G0101 CA screen; pelvic/breast
exam
As indicated by nationally recognized
clinical guidelines.
Covered only when occurs at a family
planning visit.
Comprehensive prevention family planning visit
CPT®
Code Modifier Short Description Comments
99384 FP Prev visit new age 12-17 New patient with uterus and ability
to become pregnant. Once every 365
days.
99385 FP Prev visit new age 18-39 New patient with uterus and ability
to become pregnant. Once every 365
days.
99386 FP Prev visit new age 40-64 New patient with uterus and ability
to become pregnant. Once every 365
days.
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29 | Family Planning Billing Guide
CPT®
Code Modifier Short Description Comments
99394 FP Prev visit est age 12-17 Established patient, with uterus and
ability to become pregnant. Once
every 365 days.
99395 FP Prev visit est age 18-39 Established patient, with uterus and
ability to become pregnant. Once
every 365 days.
99396 FP Prev visit est age 40-64 Established patient, with uterus and
ability to become pregnant. Once
every 365 days.
99401 FP Preventive counseling, individ Use for contraceptive counseling in
clients with penis and ability to
impregnate. Once every 365 days.
Contraceptives
See the Contraceptives Coverage Table.
Radiology services
Radiology services are covered only when medically necessary due to a family
planning complication. See Complications from contraceptive methods for how
to bill when a family planning complication occurs. See the Physician-Related
Professional Services Fee Schedule for payment rates for procedures related to a
complication.
Human papillomavirus (HPV) immunization
Family Planning Only programs cover HPV vaccine administered according to the
current Centers for Disease Control (CDC) Advisory Committee on Immunization
Practices (ACIP) immunization schedule for adults and children/minors in the
United States.
For Family Planning Only clients under age 19, refer to the EPSDT Billing Guide
for billing instructions and the Enhanced Pediatric Fee Schedule for current rates.
For Family Planning Only clients age 19 and older, refer to the Physician-
Related/Professional Services Billing Guide for billing instructions, the
Professional Administered Drug Fee Schedule for current vaccine rates, and the
Physician-Related/Professional Services Fee Schedule for current administration
code rates.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
30 | Family Planning Billing Guide
CPT® Code/HCPCs
Code Short Description Comments
90651 9vhpv vaccine 2/3 dose
im
Bill with diagnosis Z23 at line level and,
when appropriate, as primary diagnosis on
the claim. Clients under age 19, use SL
modifier. Clients age 19 and older, do not
use a modifier.
90471 Immunization admin Bill with diagnosis Z23 at line level. Clients
age 19 and older only.
Laboratory services
Laboratory services are covered when they are directly related to the client’s safe
and effective use of a chosen contraceptive method. This includes pregnancy
testing, gonorrhea and chlamydia screening and testing. Cervical cancer
screening may also be covered. Specimens must be collected at a family planning
visit to be covered by the Family Planning Only programs.
Laboratory testing in conjunction with a sterilization procedure or family planning
complication are covered. See the Physician-Related Professional Services Fee
Schedule for payment rates for laboratory services related to a sterilization or
family planning complication.
CPT® Code Short Description Comments
36415 Routine venipuncture Drawing blood venous. Payment limited to
one draw per day.
36416 Capillary blood draw
81025 Urine pregnancy test
84703 Chorionic gonadotropin assay
86592 Syphilis test non-trep qual
86593 Syphilis test non-trep quant
86631 Chlamydia antibody
86632 Chlamydia igm antibody
87110 Chlamydia culture
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31 | Family Planning Billing Guide
CPT® Code Short Description Comments
87270 Chlamydia trachomatis ag if Infectious agent antigen detection by
immuno-fluorescent technique; chlamydia
trachomatis
87320 Chylmd trach ag ia Infectious agent antigen detection by
enzyme immunoassay technique, qualitative
or semiquantitative; chlamydia trachomatis
87490 Chylmd trach dna dir probe
87491 Chylmd trach dna amp probe
87590 N.gonorrhoeae dna dir prob
87591 N.gonorrhoeae dna amp prob
87624 HPV high-risk types
87625 HPV types 16 & 18 only Includes type 45, if performed
87800 Detect agnt mult dna direc
87810 Chylmd trach assay w/optic
88141 Cytopath, c/v interpret
88142 Cytopath, c/v thin layer
88143 Cytopath, c/v thin layer redo
88147 Cytopath, c/v automated
88148 Cytopath, c/v auto rescreen
88150 Cytopath, c/v manual
88152 Cytopath, c/v auto redo
88153 Cytopath, c/v redo
88164 Cytopath tbs c/v manual
88165 Cytopath tbs c/v redo
88166 Cytopath tbs c/v auto redo
88167 Cytopath tbs c/v select
CPT® codes and descriptions only are copyright 2022 American Medical Association.
32 | Family Planning Billing Guide
CPT® Code Short Description Comments
88174 Cytopath c/v auto in fluid
88175 Cytopath c/v auto fluid redo
STD/STI treatment
The Family Planning Only programs cover limited treatment for sexually
transmitted diseases and sexually transmitted infections (STD/STI). Treatments for
gonorrhea and chlamydia only are covered. Providers must follow CDC guidelines
for treatment of STD/STIs. Single dose drugs that are recommended to be
directly observed are covered when administered in an office or clinic. All other
covered drugs must be prescribed by and then obtained from and billed by a
pharmacy.
HCPCS/CPT®
Codes Short Description Comments
96372 Ther/proph/diag inj sc/im May not be billed with an office visit.
(Specify substance or drug)
J0558 Peng benzathine/procaine inj
J0561 Penicillin g benzathine inj
J0696 Ceftriaxone sodium inj 250 mg
J1580 Garamycin gentamicin inj 80 mg. Alternative regimen*
Q0144 Azithromycin dehydrate, oral 1 g. Alternative regimen*
By prescription
only
Doxycycline 100 mg PO
By prescription
only
Cefixime 400 capsules mg PO Alternative regimen*
By prescription
only
Levofloxacin 500 mg Alternative regimen*
*Alternative regimens can be considered in instances of substantial drug allergy
or other contraindications.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
33 | Family Planning Billing Guide
What does HCA pay for?
HCA limits payment under the Family Planning programs to services that:
o Have a primary focus and diagnosis of family planning as determined by
a qualified, licensed medical practitioner.
o Are medically necessary for the client to use safely and effectively, or
continue to use, the client’s chosen contraceptive method.
What fee does HCA pay?
HCA pays:
o Providers for covered family planning services using HCA’s Family
Planning Fee Schedule.
o For family planning pharmacy services, family planning laboratory
services, and sterilization services using HCA’s published fee schedules.
o A dispensing fee only for contraceptive drugs purchased through the
340B program of the Public Health Service Act.
Family planning services provided to family planning clients by federally
qualified health centers (FQHCs), rural health centers (RHCs), and Indian health
care providers (IHCP) do not qualify for encounter or enhanced rates.
HCA requires providers to do the following:
o Meet the timely billing requirements of WAC 182-502-0150
o Seek timely reimbursement from a third party when a client has available
third-party resources, as described under WAC 182-501-0200. See Billing
for third-party liability and “good cause” for exceptions.
What does HCA not pay for?
HCA does not pay for inpatient services under the Family Planning Only
programs, except for complications arising from covered family planning
services.
Note: Billing adjustments related to the Family Planning Only
program must be completed no later than two years after the
date of service in which Family Planning Only services occurred.
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34 | Family Planning Billing Guide
Billing for third-party liability and “good cause”
HCA requires a provider under WAC 182-501-0200 to seek timely reimbursement
from a third party when a client has available third-party resources, except when
“good cause” exists.
“Good cause” means that use of the third-party coverage would violate a client’s
confidentiality because the third party:
Routinely sends written, verbal, or electronic communications, as defined in
RCW 48.43.505, to the third-party subscriber and that subscriber is someone
other than the applicant.
Requires the applicant to use a primary care provider who is likely to report
the applicant’s request for family planning services to the subscriber.
Clients eligible for Family Planning Only programs may request an exemption
from the requirement to bill third-party insurance due to “good cause” if they are
either of the following:
18 years of age or younger and seeking services in confidence
Domestic violence victims and seeking services in confidence
Note: Clients must make the self-declaration on the Family
Planning Only program client application to qualify for this
exception.
If either of these conditions applies, the applicant is considered for Family
Planning Only program without regard to the available third-party family
planning coverage.
At the time of application, providers must make a determination about “good
cause” on a case-by-case basis.
Note: To preserve confidentiality, when billing for family
planning services for either exception above, do not indicate on
the claim that the client has other insurance.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
35 | Family Planning Billing Guide
What are the requirements for Family Planning Only
programs providers?
To be paid by HCA for services provided to clients eligible for Family Planning
Only programs, providers must:
Meet the requirements in chapters 182-501, 182-502, and 182-532 WAC.
Provide only those services that are within the scope of their licenses.
Bill HCA according to this guide and other applicable HCA billing guides.
Educate clients on Food and Drug Administration (FDA)-approved
contraceptive methods and over-the-counter (OTC) contraceptive drugs,
devices, and products, as well as related medical services.
Provide medical services related to FDA-approved contraceptive methods and
OTC contraceptive drugs, devices, and products upon request.
Supply or prescribe FDA-approved contraceptive methods and OTC
contraceptive drugs, devices, and products upon request.
Refer the client to available and affordable nonfamily planning primary care
services, as needed.
Documentation requirements
In addition to the requirements in WAC 182-502-0020, providers must document
the following in the client's medical record:
Primary focus and diagnosis of the visit is family planning-related
Contraceptive methods discussed
Plan for use of a contraceptive method, or the reason and plan for no
contraceptive method
Education, counseling, and risk reduction with sufficient detail that allows for
follow-up
Referrals to, or from, other providers
Copy of the completed Consent Form for Sterilization, if applicable. (See WAC
182-531-1550)
Provider requirements specific to the Family Planning Only
program
When serving clients covered under the Family Planning Only program, providers
must do all of the following:
Participate in the research and evaluation component of the Family Planning
Only program if requested by HCA. Some services related to research and
evaluation may be contracted and billed separately.
Provide Family Planning Only program client files, billing, and medical records
when requested by HCA staff
CPT® codes and descriptions only are copyright 2022 American Medical Association.
36 | Family Planning Billing Guide
Forward the client’s Services Card and any related information to the client’s
preferred address within 5 working days of receipt if requested by the client
Ensure they have a way of reaching the client in a confidential manner if the
client requests confidentiality regarding the use of family planning services
Inform the client of his or her right to seek services from any Family Planning
Only program provider within the state.
Note: It is important for the client to have easy and immediate
access to the Family Planning Only program provider or
pharmacy of her or his choice. A client may enroll in the Family
Planning Only program at one Family Planning Only program
provider’s office and receive services at a different Family
Planning Only program provider’s office. Family Planning Only
program providers must help all potentially eligible clients enroll
in the program, regardless of where they choose to receive
services.
What contraceptives does HCA cover?
Hormonal contraceptive prescribing
HCA generally requires prescriptions for oral, transdermal, and intra-vaginal
hormonal contraceptives to be dispensed as a one-time prescription for a 12-
month supply. When specifying the dispensing quantity for these contraceptives,
prescribers should write for a 12-month supply according to the chart below,
unless there is an acceptable reason not to do so.
For prescriptions written with a dispensing quantity less than a 12-month supply,
providers will receive requests from pharmacies to change the dispensing
quantity. Providers may write the prescription for a lesser amount if any of the
following are true:
The client does not want a 12-month supply all at once.
There is a clinical reason, documented in the chart, for the client to receive a
smaller supply.
This requirement applies to clients in both fee-for-service and managed
care.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
37 | Family Planning Billing Guide
Contraceptive type
Quantity required for 12 months to be
dispensed Cycles/Packs
Oral contraceptives,
e.g. pills
364 tablets 13
Continuous oral
contraceptives
504 tablets when dispensed as 28-day packs 18
Continuous oral
contraceptives
378 tablets when dispensed as 21-day packs 13
Transdermal
contraceptives, e.g.,
patch
39 transdermal patches 13
Transdermal
contraceptives, e.g.,
patch
52 transdermal patches 18
Monthly intra-vaginal
contraceptives, e.g.,
Nuvaring
13 intra-vaginal rings 13
Monthly intra-vaginal
contraceptives, e.g.,
Nuvaring
18 intra-vaginal rings 18
Quarterly injectable
contraceptives, e.g.,
Depo-SubQ Provera
104
4 prefilled syringes 4
Note: Contraceptives are covered under Reproductive Health
Services and Family Planning Only Programs.
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38 | Family Planning Billing Guide
Hormonal contraceptives filled at the pharmacy
HCA generally requires pharmacies to dispense oral, transdermal, and intra-
vaginal hormonal contraceptives as a one-time prescription of a 12-month
supply. For prescriptions written with a dispensing quantity less than a 12-month
supply, HCA encourages pharmacies to contact the prescriber to request a
change in the dispensing quantity. Pharmacies may dispense a lesser amount if
any of the following are true:
The client does not want a 12-month supply all at once.
There is a clinical reason, documented on the prescription, for the client to
receive a smaller supply.
The pharmacy does not have enough supply to fill for 12 months.
This requirement applies to both fee-for-service and managed care.
See the Prescription Drug Program Billing Guide or the expedited authorization
code from the Apple Health EA list for more details.
Hormonal contraceptives dispensed from a family
planning clinic
12-month supply
HCA generally requires family planning clinics to dispense oral, transdermal,
injectable, and intra-vaginal hormonal contraceptives as a one-time prescription
of a 12-month supply. Clinics may dispense or write the prescription for a lesser
amount if any of the following are true:
The client does not want a 12-month supply all at once.
There is a clinical reason, documented in the chart, for the client to receive a
smaller supply.
The clinic does not have enough supply to fill for 12 months.
340B dispensing fee
A 340B dispensing fee may be billed only for designated hormonal
contraceptives which must be purchased and dispensed by a family planning
clinic participating with Medicaid in the 318-drug program under the Public
Health Service (PHS) Act. The clinic is listed on the Medicaid Exclusion File as a
318 entity (STD clinic). The 340B drugs must be billed at actual acquisition cost.
See WAC 182-530-7900.
The 340B dispensing fee may be billed only with HCPCS codes S4993, J7295,
J7294, J7304, and J1050 (Depo-SubQ Provera 104 only). The number of billed
units for S9430 must always equal the number of units dispensed by the provider
for codes S4993, J7295, J7294, and/or J7304 and be billed on the same day of
service and on the same claim. For J1050 (Depo-SubQ Provera 104 only), the
number of billed units for S9430 must equal the number of syringes dispensed by
the provider and be billed on the same day of service and on the same claim.
These requirements apply to clients in both fee-for-service and managed
care.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
39 | Family Planning Billing Guide
Note: HCA does not reimburse for any drug provided free of
charge (for example, samples obtained through special
manufacturer agreements). A dispensing fee in these cases is not
reimbursable.
HCA requires providers to list the 11-digit National Drug Code
(NDC) number in the appropriate field of the claim when billing
for all drugs administered in or dispensed from their office or
clinic.
Immediate postpartum Long-Acting Reversible
Contraceptive (LARC) insertion
HCA reimburses professional services for immediate postpartum IUD or
contraceptive implant insertion procedures if billed separately from the
professional global obstetric procedure.
HCA does not reimburse facility services for the immediate postpartum IUD or
contraceptive implant insertion procedure. These inpatient services may not be
unbundled on the hospital’s facility claim.
HCA reimburses for the IUD or contraceptive implant device in one of the
following ways:
Through the facility’s pharmacy point of sale system
As a separate professional claim submitted by the facility when the facility
supplies the device
As part of the professional claim when the device is supplied by the provider
performing the insertion
Note: When billing for an IUD or contraceptive implant device,
the provider must use the appropriate HCPCS code and NDC.
Contraceptives coverage table
Prescription contraceptives
Pills, Ring, and Patch
HCPCS Code Short Description Comments
S4993 Contraceptive pills for bc 1 unit = each 21 or 28-day pack. (Seasonale
should be billed as 3 units.) Participating
340B provider: may bill with S9430.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
40 | Family Planning Billing Guide
HCPCS Code Short Description Comments
J7295 Monthly contraceptive ring, each
(Nuvaring)
Participating 340B providers may bill with
S9430.
J7294 Yearly contraceptive ring, each
(Annovera)
Participating 340B providers may bill with
S9430.
J7304 Contraceptive hormone patch Each (Ortho-Evra). Participating 340B
provider may bill with S9430.
S9430 Pharmacy comp/disp serv A dispensing fee for participating 340B
providers.
May bill only with S4993 (birth control pills,
and emergency contraception pills), J7295
(monthly contraceptive rings), J7294 (yearly
contraceptive ring), J7304 (contraceptive
patches), J1050 (Depo-SubQ Provera 104).
For birth control pills, emergency
contraceptive pills, contraceptive rings, and
contraceptive patches:
Units of dispensing fee must match units of
contraceptive.
For Depo-SubQ Provera 104:
S9430 is payable once per syringe, rather
than per unit of medication.
Emergency Contraception
HCPCS Code Short Description Comments
S4993 Contraceptive pills for bc Unclassified drug
Used for:
Ulipristal acetate 30 mg
Ulipristal is prescription for all ages.
Each 1 unit equals one course of treatment.
Participating 340B provider may bill with
S9430.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
41 | Family Planning Billing Guide
Injectable
HCPCS Code Short Description Comments
J1050 Medroxyprogesterone acetate Injection 1 mg (Depo-Provera)
Depo-Provera IM:
No 340B dispensing fee allowed.
May be billed with injection
administration code 96372 only when
not in conjunction with an office visit.
Depo-SubQ Provera 104:
Participating 340B provider may bill with
S9430 for up to four doses. S9430 is
payable once per syringe, rather than
per unit of medication.
For in-clinic injection, may be billed with
injection administration code 96372 only
when not in conjunction with an office
visit.
Bill all units of Depo-SubQ Provera 104
on a single service line within the claim,
whether doses administered or
dispensed. Do not separate into more
than one service line.
Intrauterine Device (IUD)
HCPCS Code Short Description Comments
J7297 Liletta, 52 mg Levonorgestrel-releasing IUD. No 340B
dispensing fee allowed.
J7298 Mirena, 52 mg Levonorgestrel-releasing IUD. No 340B
dispensing fee allowed.
J7300 Intraut copper contraceptive Paragard. No 340B dispensing fee allowed
J7301 Skyla, 13.5 mg Levonorgestrel-releasing IUD. No 340B
dispensing fee allowed
J7296 Kyleena, 19.5 mg Levonorgestrel-releasing IUD. No 340B
dispensing fee allowed
CPT® codes and descriptions only are copyright 2022 American Medical Association.
42 | Family Planning Billing Guide
HCPCS Code Short Description Comments
58300 Insert intrauterine device Enhanced fee applies. See Physician-
Related Services Fee Schedule for current
rate.
58301 Remove intrauterine device
Implant
HCPCS/CPT®
Code Short Description Comments
J7307 Etonogestrel implant system Contraceptive (Nexplanon). No 340B
dispensing fee allowed.
11981 Insert drug implant device Enhanced fee applies. See Physician-
Related Services Fee Schedule for current
rate.
Must be billed with FP modifier.
11982 Remove drug implant device Must be billed with FP modifier.
11983 Remove/insert drug implant Enhanced fee applies. See Physician-
Related Services Fee Schedule for current
rate.
Must be billed with FP modifier.
11976 Remove contraceptive capsule Norplant only
Cervical Cap/Diaphragm
HCPCS/CPT®
Code Short Description Comments
A4261 Cervical cap contraceptive No 340B dispensing fee allowed
A4266 Diaphragm No 340B dispensing fee allowed
57170 Fitting of diaphragm/cap
CPT® codes and descriptions only are copyright 2022 American Medical Association.
43 | Family Planning Billing Guide
Note: For sterilization procedure codes, see the Sterilization
Supplemental Billing Guide. For instructions on billing for office,
professionally administered drugs, imaging, and laboratory
codes, see the Physician-Related Services/Health Care
Professional Services Billing Guide. For additional information
on billing for drugs, see the Prescription Drug Program Billing
Guide.
Nonprescription over-the-counter (OTC) contraceptives
Nonprescription OTC contraceptives may be obtained with a Services Card
through a pharmacy or HCA-designated family planning clinic.
HCPCS Code Short Description Comments
A4267 External Condom, each No 340B dispensing fee allowed.
A4268 Internal Condom, each No 340B dispensing fee allowed.
A4269 Spermicide Includes gel, cream, foam, vaginal film,
and contraceptive sponge.
No 340B dispensing fee allowed.
Emergency contraception
HCPCS Code Short Description Comments
S4993 Contraceptive pills for bc Unclassified drug
Used for:
Levonorgestrel 1.5 mg
Levonorgestrel is over the counter for
clients of all ages per FDA.
Each 1 unit equals one course of
treatment.
Participating 340B provider may bill with
S9430.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
44 | Family Planning Billing Guide
Nondrug contraceptive supplies (natural family planning)
HCPCS/CPT®
Code Modifier Short Description Comments
T5999 FP Supply nos Use for cycle beads only. Each 1 unit
equals one set of cycle beads.
99071 FP Patient education
materials
Use for natural family planning
booklet only. Each 1 unit equals one
booklet.
A4931 FP Reusable oral
thermometer
Use for basal thermometer only.
Each 1 unit equals one
thermometer.
Note: For fees for family planning and nonfamily planning
reproductive health services, refer to the Physician-Related
Services/Health Care Professional Services fee schedules. See
also the Professional Administered Drug Fee Schedule.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
45 | Family Planning Billing Guide
Appendix A
Clinic visit scenarios for Family Planning Only
programs
The purpose of the Family Planning Only programs is to prevent unintended
pregnancy.
Documentation in the client’s chart must reflect that the majority of the time was
spent with the client with the focus of family planning.
Example A
Amanda (she/her) has chosen to use an intrauterine device (IUD). It is the
standard of practice to screen for chlamydia/gonorrhea prior to IUD insertion.
This sexually transmitted infection (STI) screening (and treatment if necessary)
would be covered under the Family Planning Only program as it is not medically
safe to insert an IUD into a potentially infected uterus.
Example B
Beatriz (she/her) has been a client at your clinic for several years. She has been an
inconsistent condom and oral contraceptive user and at high risk for unintended
pregnancy. She decides to try the monthly intravaginal contraceptive ring and
has been using it safely and successfully for 6 months. She comes into the clinic
with complaints of spotting and bleeding especially after intercourse, which she
believes is caused by the hormones in the ring. She wants to quit the ring and go
back to condoms. She mentions something about her new boyfriend and how he
won’t be too happy about having to use condoms.
You are concerned that the bleeding may be caused by chlamydia/gonorrhea
and not her hormonal contraceptive and that she will again be at risk for
pregnancy with a method that she didn’t use well previously. You test her for
chlamydia/gonorrhea, treat her presumptively, explain the importance of her
partner getting treated and tested as well, discuss the importance of condoms for
STI prevention, and continue her with the monthly intravaginal contraceptive ring.
Her office visit, lab tests, and treatment would be covered because your thorough
charting makes the link to the safe and effective use of her contraceptive method.
Example C
Cal (they/them) comes into the clinic stating that they heard that their recent past
partner “had something” and they wanted to be checked just to be sure. They are
in a new relationship, using oral contraceptives and using condoms for STI
prevention. They are having no problems with their contraceptive method. They
just want to be screened for STIs. This visit would not be covered under the
Family Planning Only programs.
Example D
Deirdre (she/her) was taken off hormonal contraceptives when she was
diagnosed with severe mononucleosis. She was jaundiced and her liver was
enlarged during the acute phase of her illness. She is not happy using condoms,
has had unprotected sex a couple of times, and wants to resume her oral
CPT® codes and descriptions only are copyright 2022 American Medical Association.
46 | Family Planning Billing Guide
contraceptive use. You order laboratory work to determine that her liver function
has returned to normal before restarting her on pills. This visit and laboratory
tests would be covered under the Family Planning Only programs. Again, your
thorough charting of this client’s history and current presenting issues is your
justification for requesting payment from HCA for these services.
Example E
Evelyn (she/her) has come into the clinic seeking her annual exam and
contraception. She now has coverage with an HCA-contracted managed care
organization (MCO). Your clinic is a contracted provider with this MCO. Your
biller, Sherm, asks, “Who pays for these services? Medicaid? The MCO?” Because
your clinic is a contracted provider with the client’s MCO, Sherm must bill the
MCO.
CPT® codes and descriptions only are copyright 2022 American Medical Association.
47 | Family Planning Billing Guide
Appendix B
Frequently asked questions
If a client changes from Family Planning Only program coverage to full
scope Medicaid coverage, are they covered under the Family Planning Only
program?
No. The client now is eligible for Reproductive Health Services. (See Reproductive
Health Services.)
Are prostate cancer screenings, digital rectal examinations, and prostate-
specific antigen tests (PSA) covered under reproductive health services and
the Family Planning Only programs?
Prostate cancer screenings are covered under Reproductive Health Services with
the following procedure codes and diagnoses:
Individuals with a prostate are covered for HCPCS procedure code G0103 for
prostatespecific antigen test (PSA) with diagnosis code Z12.5 (encounter for
screening for malignant neoplasm of the prostate).
A digital rectal exam (HCPCS procedure code G0102) is bundled into the
reimbursement for the office visit.
These prostate cancer screenings are not covered under the Family Planning Only
programs.
Are mammograms covered under reproductive health services and the
Family Planning Only programs?
Mammograms are covered for clients under Reproductive Health Services. For
more information, refer to the Physician-Related Professional Services Billing
Guide. Mammograms are not covered under the Family Planning Only programs.
Are abortions covered under reproductive health services and the Family
Planning Only programs?
Abortions are covered for clients under Reproductive Health Services. Bill HCA for
these services with a medical taxonomy.
Abortions are not covered under the Family Planning Only programs.
Note: If a Family Planning Only programs client becomes
pregnant, refer the client to the Washington Healthplanfinder's
website or call 1-855-923-4633 to determine if the client
qualifies for medical services under another program.