Contraceptive Medically Unlikely Edit (MUE)

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Apple Health (Medicaid) Provider Alert

Effective for claims with dates of service on and after January 1, 2019, the Centers for Medicare & Medicaid Services (CMS) will implement an edit for contraceptive codes J7303 (vaginal ring) and J7304 (transdermal patch) to limit billing to 1 unit per line on a claim.

The Health Care Authority (HCA) requires Apple Health providers to dispense a full 12-month supply of contraceptives per WAC 182-530-2000; therefore we are asking CMS to waive the NCCI edit to avoid administrative burden to our providers and maintain access to adequate contraception for our clients. We most likely will not receive a response before January 1.

Providers should continue to dispense the required amount of contraceptive based on HCA requirements and the client’s needs.

Until HCA receives an answer from CMS, you may:

  • Delay billing for these two contraceptives until we notify you of our resolution with CMS; or
  • Provide a prescription for the client to take to a pharmacy, as this edit does not apply to pharmacy dispensed contraceptives; or
  • Bill either HCA or the client’s MCO by entering 1 unit per line on the claim for as many lines as the number of units dispensed.

Thank you for your patience. For questions or concerns contact HCA Family Planning.