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MHCP Provider Manual — Minnesota Family Planning Program (MFPP): (Chapter 10 – Overview) <br> This section includes MHCP coverage and billing policy for the Minnesota Family Planning Program (MFPP) providers. MHCP offers MFPP as a separate set of Family Planning services. Provider, recipient, and service delivery requirements are not the same for MFPP and non-MFPP MHCP family planning services Refer to the Chapter 10 overview page for links to other related services. <br> The Minnesota Family Planning Program (MFPP) provides family planning services and supplies for women and men ages 15 years to 50 years, (eligibility begins the first day of the month of the 15th birthday through the end of the month of the 50th birthday), who are not eligible for other MHCP programs, and meet certain income guidelines. The main goal of MFPP is to reduce the number of unintended births, thereby reducing costs to Minnesota’s publicly funded health care programs. Eligible Providers The following enrolled MHCP providers are eligible to provide services to MFPP recipients: Ambulatory surgical centers Anesthesiologists and CRNAs Certified nurse midwives Clinical nurse specialists Community health clinics Family planning agencies Federally Qualified Health Centers (FQHCs) Indian Health Services (IHS/638 facilities) Laboratories Nurse practitioners Outpatient hospital departments Pharmacies Physician assistants Physician-directed clinics Physicians Public health clinics Rural health clinics (RHCs) Dispensing by Protocol – Family Planning Registered Nurse A registered nurse (RN) in a family planning agency may dispense oral contraceptives prescribed by a licensed practitioner, according to a dispensing protocol established by the agency’s medical director or under the direction of a physician. RNs may not dispense oral contraception to a recipient who is less than twelve years of age. Follow state requirements for dispensing prescription drugs. Presumptive Eligibility Presumptive eligibility is a short-term period of eligibility determined at the point of service by a certified MFPP provider. At the time a presumptive eligibility determination is made, the certified MFPP provider gives the applicant a MFPP Short-Term Approval Notice, available online through the MN–ITS site. Other providers, including pharmacies and labs, should accept this form as proof of eligibility for the dates indicated. MFPP Provider Certification Certified MFPP providers are individuals and clinics providing primary family planning services that are certified by DHS to determine presumptive (short-term) eligibility for MFPP. Individual providers working in a certified clinic do not need separate certification when the clinic itself is certified. To become certified, a provider must have participated in MFPP training or complete the online training course, and submit the completed Certified Family Planning Provider Application Packet to: DHS P.O. Box 64961 St. Paul, MN 55164-0961 Certified MFPP providers prescribing medication or supplies must: Contact the Pharmacy before you fax both sides of the MFPP Rx Form (available in MN–ITS) (do not give to the recipient) and a copy of the recipients short term approval letter to the pharmacy. Pharmacies should be prepared to accept prescriptions and immediately dispense medications and supplies listed on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period. Only the medication and supplies listed on the MFPP Rx Form are covered at the pharmacy for this program Give presumptively eligible recipients the MFPP Short-Term Approval Notice to take with them to the pharmacy. The form allows you to provide at least 2 of 3 identifiers (recipient first and last name, date of birth, SSN) sufficient for the pharmacy to verify recipient MFPP eligibility using MN–ITS, EVS, or POS Pharmacy Services When certified MFPP providers fax a MFPP Rx Form and a Short-Term Approval Notice to pharmacies, and the recipient presents a copy of the Short-Term Approval Notice to the pharmacy, MHCP is asking pharmacies to work with the MFPP provider and dispense the medications and supplies indicated on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period. Only medications and supplies listed on the MFPP Rx Form are covered on MFPP at the pharmacy. MHCP asks pharmacies to wait three business days to bill for the initial dispense of MFPP medication and supplies, to allow the recipient’s eligibility status to appear in our MHCP system. MHCP will reimburse pharmacies for MFPP related medications and supplies during the presumptive eligibility period, even if it is later determined the individual was not eligible for more than the initial two months of MFPP. Referrals to Other Providers Physicians, APRNs, clinics and family planning agencies serve as the primary care providers for recipient reproductive health services. Providers must make available to MFPP eligible recipients all services in the MFPP benefit package either directly or by referral Refer recipients only to enrolled MHCP providers, as recipients must not be billed Provide the primary diagnosis (V25. to V25.9 range), and any secondary diagnosis that applies. Have at least 2 of 3 identifiers (recipient first and last name, date of birth, SSN) sufficient for an outside lab or other providers to verify recipient MFPP eligibility using MN–ITS or EVS, and bill for services performed. When recipients require access to primary care services, provide them with the most current Primary Care Resources form DHS4741, Distribute the MFPP proof of income, immigration status, citizenship & identity form, DHS-4900, to applicants & recipients with questions about verification requirements. Additional MFPP forms are also available from the MFPP office at (651) 431-3480 or 1-888-702-9968. Eligible Recipients Certified MFPP providers will determine MFPP eligibility at the point of service. MFPP applicants may apply on their own behalf without the consent of anyone else. Eligibility for individuals under age 21 is not based on parental income. An eligible recipient for MFPP must: Be age 15 years to 50 years, (eligibility begins the first day of the month of the 15 th birthday through the end of the month of the 50th birthday) Be a Minnesota resident Be a citizen or a qualified non-citizen Have income at or below 200% federal poverty guidelines (FPG) (individuals under age 21 are eligible based on their own income) Not pregnant Not institutionalized Recipients have initial presumptive (short-term) eligibility for the month the MFPP provider determines them eligible, through the last day of the following month. MHCP will determine the recipient’s continued MFPP eligibility. If found eligible, the recipient has MFPP coverage for an additional twelve months. MFPP eligibility ends before the annual renewal if the recipient has one of the following occur: Is no longer a Minnesota resident Voluntarily terminates eligibility Become eligible for MA, GAMC, or MinnesotaCare Turns age 50 years (eligibility terminated at the end of the month of the 50th birthday) Becomes pregnant Becomes institutionalized Confidentiality All partner agencies of the Minnesota Department of Human Services (DHS) are required to comply with federal and state laws that protect the privacy and security of individually identifiable client information. Responsibility to Protect Private Data You are responsible to protect individually identifiable information about applicants for, or enrollees in, DHS services and program benefits. IMPORTANT: Privacy protection applies to Minnesota Family Planning Program (MFPP) eligibility and benefits information. This information is private data on individuals and cannot be released to anyone other than the subject of the data without the data subject’s consent, or unless the law otherwise allows. Responsibility to Protect Privacy of Minors Remember that minors may apply for the MFPP without parental consent. IMPORTANT: Do not release information about a minor’s MFPP eligibility or benefits to a parent, guardian or caretaker without the minor’s informed consent. In addition to MHCP confidentiality protection, MFPP applicants and recipients also have the following protections: MFPP services do not appear on any explanations of medical benefits (EMOBs) to the recipient or recipient’s family. MFPP applicants and recipients may choose to receive notices at an address other than a home address MFPP applicants and recipients are not required to provide information about their third party liability (other insurance) if they are concerned it may compromise their safety or privacy. If no other insurance is listed when verifying eligibility on MN-ITS or EVS, do not bill the insurance, even if you have a record of that insurance from a previous visit to your office. Only bill other insurance if the insurance is listed on the current eligibility response Covered Services Verify Eligibility Use an MFPP recipient’s Approval Notice as proof of MFPP presumptive eligibility. After the initial three business days, verify eligibility and obtain the recipient’s ID number using MN–ITS or the phone based eligibility verification system at (651) 431-4399 or 1-800-657-3613. The system will denote MFPP eligibility with major program code FP. If the recipient is ineligible or you cannot obtain the ID number, contact an MFPP Eligibility Specialist at (651) 431-3480 or 1-888-702-9968. MFPP covers only family planning related services and supplies, and treatment of sexually transmitted infections (STIs) diagnosed in conjunction with a family planning service (listed below): Family planning office visits, exams, counseling and education Contraceptive medications and supplies Pharmacy services Voluntary sterilization Laboratory tests Diagnosis, testing, and treatment of STIs found during a family planning visit HIV testing and counseling Mammograms are not a covered MFPP service. For women who require a mammogram, the Minnesota Department of Health (MDH) SAGE Program may be an option if they meet program requirements. Recipients may be eligible for both the SAGE Program and MFPP. Report all primary MFPP services with a primary ICD-9-CM diagnosis code in the V25 – V25.9 range. Report secondary services with the appropriate primary diagnosis code; refer to the Secondary MFPP Services section. Family Planning Office Visits, Exams, Counseling and Education MHCP covers the following office visits, exams, counseling and education for MFPP: MFPP Office Visits, Exams, Counseling and Education Code/Range Description 99078 Physician Education 99201 - 99215 Office or other outpatient visit, new or established patient 99384 - 99386 Initial preventive medicine 99394 - 99396 Periodic preventive medicine H1010 Non-medical family planning education, per session 99401 - 99412 Preventive medicine, individual or group counseling <br> Refer to the Lab Services section when ordering lab tests. Contraceptive Medications and Supplies Contact the Pharmacy before you fax both sides of the MFPP Rx Form (available in MN–ITS) (do not give to the recipient) and a copy of the recipients short term approval letter to the pharmacy. Pharmacies should be prepared to accept prescriptions and immediately dispense medications and supplies listed on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period. MFPP covers only the following contraceptive medications and supplies that are directly related to family planning and associated reproductive health issues provided in the clinic setting: MFPP Contraceptive Medications and Supplies Code Description A4261 Cervical cap for contraceptive use A4266 Diaphragm A4267 Contraceptive supply, male A4268 Contraceptive supply, female A4269 Contraceptive supply, spermicide, each *J1055 Medroxyprogesterone acetate for contraceptive use (Depo) J7300 Intrauterine copper contraceptive *J7302 Levonorgestrel releasing IUD system *J7303 Contraceptive Vaginal Ring *J7304 Contraceptive Patch *J7306 Levonorgestrel implant system, including implant and supplies J7307 Etonogestrel implant system, including supplies *S4989 Contraceptive IUD (Progestacert) *S4993 Oral contraceptives, including emergency contraception, use modifier FP 11975 Insertion, implantable contraceptive capsules 11976 Removal, implantable contraceptive capsules 11977 Removal with reinsertion, implantable contraceptive capsules 57170 Diaphragm or cervical cap fitting with instructions 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) 96372 Dates of service on/after 1/1/09Therapeutic injection (Depo) *Indicates the HCPCS code requires an NDC dispensing unit and the quantity when billing MHCP. Refer to NDC Reporting Clarification for additional information. Pharmacy Services MFPP covers the following contraceptives, anti-infectives, and antifungals dispensed at a pharmacy: MFPP Contraceptives MFPP Anti-Infectives and Antifungals *generic Kariva (21-5) *Acyclovir 200mg 400mg 800mg *generic Loestrin (1.0-0.02) (1.5-0.03) *Amoxicillin 250mg 500mg *generic Alesse-28 (0.1-0.2) *Azithromycin 250mg 500mg *generic Triphasil-28 (6-5-10) Benzoin *genericNordette-28 (0.15-0.03) Benzoin Compound *generic Ortho Micronor (0.35) Benzoin/Isopropyl Alcohol Ovral-21 (0.5-0.05) Ceftriaxone (IM) 250mg 500mg 1gm *generic Lo/Ovral-28 (0.3-0.03) *Ciprofloxacin 250mg 500mg 750mg *generic Demulen 1/35E (1.0-0.035) *Clindamycin 150mg 1/50E (1.0-0.05) *generic Ortho-Novum (1.0-0.035) (1.0-1.05) *Doxycycline hyclate 50mg75mg 100mg *generic Ortho-Cyclen (0.25-0.035) *Erythromycin 250mg 333mg 500,mg Emergency contraceptive - Plan B generic Famciclovir 250mg 500mg Diaphragm Imiquimod Cervical Cap Levofloxacin 250mg 500mg Male or Female Condom *Metronidazole 0.75% 250mg 500mg Nuvaring Nitrofurantoin 25 mg 50 mg 100 mg Ortho Evra Patch Ofloxocin 300mg 400mg Other Contraceptive Supply – Spermicide Podofilox 0.5% Podophyllum Resin 0.25% *Probenecid 500mg *Sulfamethox/Trimethprim 800/160mg Trichloroacetic Acid Clotrimazole tablet (Femcare) 100mg *Clotrimazole cream 21gm 22.2gm 45gm 1% 2% *Fluconazole 50mg 100mg 150mg 200mg Miconazole suppository 100mg 200mg Micolazole cream 45 mg 2% 4% Miconazole 200mg/2% combo pack Terconazole 80 mg (Terazol 3) *Terconazole 0.40% (Terazol 7 cream) *Terconazole 0.80% (Terazol 3 cream) Tindamax (for Metronidazole intolerance) 250 mg 500 mg *MFPP will pay at generic MAC Sterilization Services Refer to Sterilization for service, consent, and timeline requirements. MFPP Sterilization Procedures Code Description 00851 Anesthesia, tubal ligation/transection 00921 Anesthesia, vasectomy 55250 Vasectomy, unilateral or bilateral (separate procedure), including postop semen exam 58340 Catheterization and introduction of saline or contrast (Essure) Hysteroscopy, surgical with bilateral fallopian tube cannulation to induce occlusion 58565 (Essure) 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic 58615 approach 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (e.g., bland, clip, or Falope 58671 ring) Lab Services Certified MFPP providers may perform lab tests in-house (according to their accreditation) or send them to an outside lab. See billing section on specific billing instructions for Lab Services. Independent lab providers should use the recipient’s ID number, the primary diagnosis and any additional diagnosis provided by the primary care provider to verify a recipient’s eligibility or wait up to three business days before using the information on the MFPP Short-Term Approval Notice to verify eligibility using MN–ITS or EVS. Code/Range 80061 80076 81000 - 81015 81025 82270 82465 82670 82746 82947 MFPP Lab Services Description Lipid panel (see CPT for tests that must be included in the panel) Hepatic function panel Routine Urinalysis Urine Pregnancy Test (kit) Blood Occult Cholesterol, serum or whole blood, total Estradiol level (monitor Depo) Folic acid; serum Glucose; quantitative, blood (except reagent strip) 82951 83001 - 83002 83020 83986 84146 84443 84703 85002 85004 - 85008 85013 - 85025 85027 85032 85049 85610 85651 - 85652 85730 86592 - 86593 86689 86695 - 86696 86701 - 86703 86706 86781 86803 87070 87075 87081 87086 87088 87109 87110 87140 87181 - 87184 87205 87206 87207 87210 87252 87254 87255 87270 87273 - 87274 87285 87320 87340 87350 87390 - 87391 87449 Glucose tolerance test, 3 specimens Gonadotropin, follicle stimulating hormone (FSH), luteinizing hormone (FSH) Hemoglobin fractionation and quantitation pH, body fluid, except blood Prolactin TSH Gonadotropin, chorionic (HCG) qualitative Bleeding time Blood count; auto, manual diff., blood smear/microscopic exam Blood count; hematocrit, hemoglobin, complete/automated Hemogram and platelet count, automated Hematology and Coagulation, manual cell count, each Blood count, platelet, automated Prothrombin time Sedimentation rate, erythrocyte; non-automated, automated Thromboplastin time Syphilis test; qualitative (e.g., VDRL, RPR, ART) HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Herpes simplex, Type 1 or 2 HIV-1, HIV-2, HIV-1 and HIV-2/single assay Hepatitis B antibody Antibody; Treponema Pallidum, confirmatory test (e.g., FTA-abs) Hepatitis C antibody Culture, bacterial; any other source except urine, blood or stool, aerobic Any source, anaerobic with isolation and presumptive ID of isolates Culture, presumptive, pathogenic organisms, screening only Culture, bacterial; quantitative colony count Culture, bacterial; with isolation and presumptive identification of each Culture, mycoplasma, any source Culture, chlamydia, any source Culture typing, Herpes Susceptibility studies; antimicrobial agent, disk method Smear, primary source with interpret; Gram or Giemsa stain Fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types Special stain for inclusion bodies or intracellular parasites (e.g., malaria, coccidia, microsporidia, cytomegalovirus, herpes viruses Wet mount for infectious agents Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathetic effect Centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus Herpes culture Infectious agent antigen detection by immunofluorescent technique; Chlamydia Herpes simplex virus type 2; type 1 Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum Infectious agent antigen detection by enzyme immunoassay technique; Chlamydia Hepatitis B surface antigen (HBsAg) Hepatitis B antigen HIV-1; HIV-2 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, not otherwise specified, each organism 87490 87491- 87492 87590 87591 87592 87620-87621 87622 87797-87799 87800 88141 - 88167 88174 - 88175 88300 88302 89300 Infectious agent detection by nucleic acid; Chlamydia Chlamydia trachomatis, amplified probe technique; quantification Infectious agent detection by nucleic acid; Gonorrhoeae, direct probe technique Neisseria gonorrhoeae, amplified probe technique Gonorrhoeae, quantification Papillomavirus, human, direct probe technique; amplified probe technique Infectious agent detection by nucleic acid; Papillomavirus, human, direct probe tech. Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism; amplified probe technique, each organism; Quantification, each organism Infectious agent detection by nucleic acid; multiple organisms, direct probe technique Pap smear codes Pap smear codes Level I - Surgical pathology, gross examination only Level II — Surgical pathology, gross and microscopic examination Semen analysis; presence or motility of sperm Miscellaneous MFPP Services MHCP covers the following miscellaneous services when provided as part of MFPP: Miscellaneous MFPP Services Code Description Q0091 Screening pap smear; obtaining, preparing and conveyance of cervical or vaginal smear T1013 Oral language interpreter services 36415 Venipuncture 36416 Collection of capillary blood specimen 74000 Radiologic exam, abdomen, single anteroposterior view 76856 Ultrasound, pelvic (nonobstetric) with image documentation. Only covers IUD surveillance 77080 Dual-energy x-ray absorptiometry (DXA) bone density study 1 or more sites, axial skeleton Dual-energy x-ray absorptiometry (DXA) bone density study 1 or more sites, appendicular 77081 skeleton (peripheral) Secondary MFPP Services Services for some secondary conditions are a program benefit only when they are provided as part of, or follow-up to, a primary family planning service mentioned in the previous sections. Only procedure codes listed in the Secondary MFFP Services chart are covered under MFPP if the services are one of the following: Provided on the same date of service as the primary family planning services and billed with a primary diagnosis code in the V25 – V25.9 range Provided as follow-up to a previous primary family planning visit (reported with a primary diagnosis code V25 – V25.9) within the preceding 180 days only if the recipient is still eligible on MFPP Report secondary services without a family planning service, for the date of service within 180 days of, the primary family planning visit, and with the most appropriate ICD-9-CM primary diagnosis code. Code/Range J0570 J0580 *J0696 Secondary MFPP Services Description Injection, penicillin G benzathine, up to 1,200,000 units Injection, penicillin G benzathine, up to 2,400,000 units Injection, ceftriaxone sodium (Rocephin) *J8499** *Q0144 10060 10140 17110 54050 54056 56501 57061 57452 57454 - 57456 57460 - 57461 57510 - 57511 88305 88307 Prescription drug, oral, NOS Use to report CDC recommended drugs for treatment of STIs when dispensed in the office, for example Amoxicillin, Cefixime, Ciprofloxacin, Clindamycin, Clotrimazole, Doxycycline, Fluconazole, Metronidazole, Nitrofurantoin, Ofloxacin, Sulfa-methoxazole/Trimethoprim, Terconazole. List the drug, dosage and number of tablets dispensed in the comments section of the services tab for that individual service line in MN-ITS or on the CMS-1500 claim form Azithromycin, oral capsule (Zithromax) Incision and drainage of abscess Incision and drainage of hematoma Destruction of warts Destruction of lesions, penis, simple; chemical Destruction of lesions, penis, simple; cryosurgery Destruction of lesions, vulva; simple Destruction of vaginal lesions; simple Colposcopy of the cervix including upper/adjacent vagina Colposcopy, with biopsy of cervix and/or endocervical curettage Colposcopy, with loop electrode biopsy of the cervix, conization of cervix Cautery of cervix; electro or thermal; cryocautery, initial or repeat Level IV - Surgical pathology, gross and microscopic examination Level V - Surgical pathology, gross and microscopic examination *Indicates the HCPCS code requires an NDC when billing MHCP. **In addition to the NDC, J8499 continues to require the drug, dosage and number of tablets dispensed in the comments section. Non-Covered Services MFPP does not cover the full MHCP benefit set. MFPP does not cover the following services: Pregnancy-related services beyond the original diagnosis Treatment for HIV/AIDS Reversal of voluntary sterilization Fertility drugs and all associated services Artificial insemination, including in-vitro fertilization Family planning services provided in an inpatient hospital setting Abortions (contraceptives provided immediately following an abortion are not considered part of the abortion service and are covered by MFPP) Pharmacy services for Medicare D dual eligibles Billing MFPP reimbursement rates are the same as MHCP fee for service reimbursement rates. Recipients may not be charged or billed for MFPP services. MFPP services have no copays. Bill using MN–ITS 837P or the CMS-1500 FQHC/RHCs: Bill using the MN–ITS 837P or the CMS-1500. Indicate each service provided. MHCP will reimburse your encounter rate For recipients eligible for MFPP (major program code FP), MHCP will cover only the services/drugs/supplies described in this section Providers billing for in-house or reference (outside) laboratory services provided with other family planning services on the same day must use a primary diagnosis codes in the V25 – V25.9 range. For services provided on a different day not related to a family planning visit use the appropriate ICD-9 CM diagnosis code Bill other insurance only if insurance is listed on the current eligibility response Billing for Lab Services Providers billing for reference (outside) laboratory services must indicate place of service 81 (independent lab) the reference lab’s NPI as the treating provider and use modifier 90 (reference lab). If you send lab test to an independent lab and that lab bills for the MFPP-covered services, include the following information to the lab, so the lab will be able to bill for the services they provide: Primary diagnosis code in the V25 – V25.9 range Secondary (etc.) ICD-9-CM diagnosis code(s) as appropriate Recipient’s ID number If lab tests are for a presumptively eligible recipient who does not yet have a recipient ID number, send a copy of the recipient’s MFPP Short-Term Approval Notice, which gives the lab provider at least 2 of 3 identifiers (recipient first and last name, date of birth, SSN) to verify recipient MFPP eligibility using MN–ITS or EVS. Because of confidentiality regulations, and to avoid the risk of a lab sending a bill to an MFPP recipient, MFPP-certified providers may choose to provide the lab with their own mailing address. Legal References MS 9505.5305 (definitions) MS 9505.5310 (eligibility, application, enrollment, and documentation) MS 9505.5315 (providers of family planning services) MS 9505.5325 (appeals) Back to Top