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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)
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