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Family Planning Billing Guide

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Family Planning Billing Guide Washington Apple Health (Medicaid) Family Planning Billing Guide Including: Reproductive Health Services, Family Planning Only – Pregnancy Related program and Family Planning Only program October 1, 2020 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, HCA rules apply. 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 [email protected]. About this guide1 This publication takes effect October 1, 2020, 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 2019 American Medical Association. 2 | FAMILY PLANNING BILLING GUIDE 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 2019 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? Subject Change Reason for Change Apple Health Changes for Removed Apple This section is January 1, 2020 Health Changes unnecessary as it is section outdated. All regions are now fully integrated managed care. Integrated managed care Removed listing of This section is regions regions and their unnecessary as it is conversion dates outdated. All regions are now fully integrated managed care. CPT® codes and descriptions only are copyright 2019 American Medical Association. 3 | FAMILY PLANNING BILLING GUIDE Table of Contents Resources Available .......................................................................................................................... 6 Definitions ............................................................................................................................................ 7 General ................................................................................................................................................... 9 How do I verify a client’s eligibility? .................................................................................... 9 Verifying eligibility is a two-step process: .................................................................... 9 Are clients enrolled in an HCA-contracted managed care organization (MCO) eligible? .......................................................................................................................................... 10 Managed care enrollment ................................................................................................. 10 Apple Health – Changes for January 1, 2020 . Error! Bookmark not defined. Clients who are not enrolled in an HCA-contracted managed care plan for physical health services ...................................................................................................... 10 Integrated managed care .................................................................................................. 11 Integrated managed care regions ................................................................................. 11 Integrated Apple Health Foster Care (AHFC) Error! Bookmark not defined. Fee-for-service Apple Health Foster Care ....... Error! Bookmark not defined. Provider Requirements ........................................................................................................... 12 Confidentiality, consent, and release of information ........................................... 13 Nationally recognized clinical guidelines................................................................... 13 How do I bill claims electronically? ............................................................................... 14 How do providers bill for managed care services? ................................................ 14 How do providers who participate in the 340B drug pricing program bill for drugs and dispensing fees? ....................................................................................... 15 Reproductive Health Services ................................................................................................... 16 What are reproductive health services? .......................................................................... 16 Who is eligible for reproductive health services? ....................................................... 16 Managed care clients .......................................................................................................... 16 Self-referral for managed care clients ......................................................................... 16 Limited coverage ................................................................................................................... 17 Where can Washington Apple Health clients receive reproductive health services? ......................................................................................................................................... 17 What are the requirements for providers? ..................................................................... 17 What reproductive health services are covered? ........................................................ 18 What reproductive health services are not covered? ................................................ 19 What fee does HCA pay? ........................................................................................................ 19 Family Planning Only Programs .............................................................................................. 20 What is the purpose of the Family Planning Only programs? .............................. 20 CPT® codes and descriptions only are copyright 2019 American Medical Association. 4 | FAMILY PLANNING BILLING GUIDE Who is eligible?........................................................................................................................... 20 Family Planning Only – Pregnancy Related program ........................................... 20 Family Planning Only program ....................................................................................... 20 What services are covered under the Family Planning Only programs? .......... 22 Complications from contraceptive methods ............................................................ 23 What drugs and supplies are covered under the Family Planning Only programs? ..................................................................................................................................... 24 Coverage table ............................................................................................................................ 24 Office visits for family planning surveillance and follow-up visits ................. 25 Comprehensive prevention family planning visit ................................................... 25 Contraceptives ........................................................................................................................ 26 Radiology services ................................................................................................................ 26 Laboratory services .............................................................................................................. 26 STD/STI treatment ................................................................................................................ 28 What does HCA pay for? ........................................................................................................ 30 What fee does HCA pay? ........................................................................................................ 30 What does HCA not pay for? ................................................................................................ 30 Billing for third-party liability and “good cause” .......................................................
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