Contraceptive Medically Unlikely Edit (MUE) – Correction to previous instructions for J7303 and J7304

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Apple Health (Medicaid) Provider Alert

This notice supersedes the Provider Alert sent December 19, 2018, from the Health Care Authority (HCA) regarding the contraceptive medically unlikely edits (MUE) for procedure codes J7303 and J7304. There is no change to billing requirements effective January 1, 2019.

On December 20, 2018, HCA received notice that the Centers for Medicare & Medicaid Services (CMS) gave permission for states to deactivate the edit for contraceptive codes J7303 (vaginal ring) and J7304 (transdermal patch) for the first quarter of 2019.

Providers should continue to dispense the required amount of contraceptive based on HCA requirements and the client’s needs. HCA will continue to accept claims where the total number of units dispensed is listed on one claim line.

HCA requires providers to dispense a full year’s supply of contraceptives (WAC 182-530-2000). This means dispensing 13 units if the client is on a 28-day cycle or 18 units if the client is on a continuous 21-day cycle. CMS has indicated that in April 2019 the limit will be 12 units per line on a claim.

HCA is requesting CMS waive the NCCI edit for Washington State to avoid administrative burden to our providers and to maintain access to adequate contraception for our clients. We will provide an update to this notice when we receive an answer from CMS.

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