20-223 Prop 56 Payments for Family Planning

Date: 06/05/20

As of July 1, 2019, for non-oral contraceptives, pregnancy testing and sterilization services

Directed payments for family planning services have been approved in the following categories.

Emergency contraceptives when provided as a medical benefit.
Long-acting contraceptives.
Other contraceptives (other than oral contraceptives) when provided as a medical benefit.
Pregnancy testing.
Sterilization procedures (for females and males).

Attachment A below shows the qualifying CPT codes and their rates by category. The fixed rate is in addition to Medi-Cal’s approved minimum allowed amount or contracted rates for the same service. Directed payments for family planning services are expected to continue annually and are subject to approval and availability of state funding.

Requirements to qualify

A qualified provider is one who is licensed to furnish family planning services within their scope of practice, is an enrolled Medi-Cal provider, and furnishes family planning services to a California Health & Wellness Plan (CHWP) member.

Qualified in-network and out-of-network providers who perform family planning services are eligible for the directed payments.
Members can choose any qualified family planning provider, including out-of-network, without a prior authorization to obtain these services.
Submit a clean claim or accepted encounter with one of the qualifying CPT codes within one year after the date of service.
Ensure the independent practice association (IPA) submits your encounters timely and accurately, if contracted through an IPA.

Payments

For clean claims or accepted encounters, supplemental payments are made within 90 calendar days of receiving funds from the Department of Health Care Services (DHCS). This applies to the first payment for the service period July, 2019, through March, 2020.

Payments for qualifying services given on April 1, 2020, and after, will be made within 90 calendar days from receipt of a clean claim or accepted encounter.

Excluded from supplemental payments

The following are not eligible for Prop 56 payments for family planning services:

Services for the following CPT codes billed with modifier UA or UB are excluded from supplemental payments: 11976, 11981, 58300, 58301, 55250, 58340, 58555, 58565, 58600, 58615, 58661, 58670, 58671, and 58700.
Federally Qualified Health Centers
Rural Health Clinics
American Indian Health Programs
Cost-based Reimbursement Clinics
Dually eligible members with Medi-Cal and Medicare Part B

Update your W-9 form

If you have not submitted a W-9 in the past 12 months or if your information has changed, submit a new form by fax or email (see Send in your W-9 form by email or fax below).

The W-9 form must include the physician’s:

Current address used to receive checks.
Individual taxpayer identification number (TIN).
National Provider Identifier (NPI) – If two or more NPIs are used (individual and group), include both NPIs where space is available.

Send in your W-9 form by email or fax

You can download the most current form from the Internal Revenue Service (IRS) website with complete instructions.

Email:

HNCA_W9_Submissions@Centene.com

(Add the words “Prop 56 W9” in the subject line.)

Fax:

1-833-794-0423

(Include a cover sheet and clearly add the words “Prop 56 W9” and “PROTECTED HEALTH INFORMATION.”)

How to file a grievance related to your family planning payment

Include the provider’s:

Last name
First name
Office address
Email address
TIN
NPI

Email:

HNCA_DirectPay@healthnet.com

(Add the words “Prop 56 Grievance” in the subject line.)

Fax:

1-844-929-0402

(Include a cover sheet and clearly add the words “PROTECTED HEALTH INFORMATION.”)

Contact the Direct Pay team by email or fax with the provider’s information above.

For more information on these approved directed payments for family planning services, refer to DHCS All Plan Letter (APL) 20-013, distributed on May 13, 2020. You can also visit the DHCS website.

If you have questions about the status of your W-9, Prop 56 payments or requesting a Remittance Advice (RA), contact CHWP at 1-877-658-0305.

Attachment A: Directed payment amounts for family planning services as of July 1, 2019

Category	HCPCS/CPT code	Description	Amount
Emergency	J3490,U5	Emergency contraception: Ulipristal acetate, 30 mg (pill)	$72
Emergency	J3490,U6	Emergency contraception: Levonorgestrel, 0.75 mg (2) and 1.5 mg (1) (pill)	$50
Contraceptives, other (non-oral)	J3490,U8	Depo-Provera^® (injection)	$340
	J7303	Contraceptive supply, hormone containing vaginal ring, each	$301
	J7304	Contraceptive supply, hormone containing patch, each	$110
	J7307	Etonogestrel (contraceptive) implant system, including implant and supplies (arm implant)	$2,671
	11976¹	Removal, implantable contraceptive capsule	$399
	11981¹	Insertion, non-biodegradable drug delivery implant	$835
IUD, long-acting	J7296	Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena^®), 19.5 mg	$2,727
	J7297	Levonorgestrel-releasing intrauterine contraceptive system, (Liletta^®), 52 mg	$2,053
	J7298	Levonorgestrel-releasing intrauterine contraceptive system. (Mirena^®), 52 mg	$2,727
	J7300	Intrauterine copper contraceptive	$2,426
	J7301	Levonorgestrel-releasing intrauterine contraceptive system, (Skyla^®), 13.5 mg	$2,271
	58300¹	Insertion of intrauterine device	$673
	58301¹	Removal of intrauterine device	$195
Sterilization, male and female	55250¹	Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) (male)	$521
	58600¹	Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral (female)	$1,515
	58615¹	Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope Ring^®) vaginal or suprapubic approach (female)	$1,115
	58661¹	Laparoscopy, surgical with removal of adnexa structures (partial or total oophorectomy and/or salpingectomy) (female)	$978
	58670¹	Laparoscopy, surgical; with fulguration of oviducts (with or without transection) (female)	$843
	58671¹	Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope Ring) (female)	$892
Surgical, other includes diagnostic	58340¹	Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography (catheterization)	$371
	58555¹	Hysteroscopy, diagnostic (separate procedure)	$322
	58565¹	Hysteroscopy, surgical, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants	$1,476
	58700¹	Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) (hysteroscopy, surgical)	$1,216
Test, lab	81025	Urine pregnancy test, by visual color comparison methods	$6

¹These CPT codes are excluded from supplemental payments when billed with modifier UA or UB.