QUEST Integration - Contraceptive Services – Long-Acting Reversible Contraceptives (LARC)

Long-Acting Reversible Contraceptives (LARC)

• Includes insertion by obstetrician or gynecologist.
• Removal and insertion/reinsertion are surgical benefits.
• Payment for insertion and removal includes office visit and consultation.

HMSA reimburses for LARC devices such as contraceptive implants and intrauterine devices (IUD).

Prior authorization is not required for preventive contraceptive procedures, methods, or devices included in an HMSA QUEST formulary with exception of the following:

1. Medically necessary indications requiring prescription of brands outside of HMSA formularies will require prior authorization.
2. Reinsertion of contraceptive implants requires prior authorization if performed during the period of effectiveness (e.g. for Implanon, the period of effectiveness is three years).

Reimbursement for LARC devices:

• Will be based on submission of appropriate HCPCs, Level II supply code and NDC number.
• A claim for a LARC device supplied by a provider other than an inpatient facility must be billed by the provider on a CMS 1500 claim form. For inpatient, the place of service must indicate “inpatient” (21) in box 24b. The 11-digit device-identifying NDC number is placed in the shaded portion of box 24a directly preceded by “N4.”

Reimbursement for a LARC device and LARC-related services, provided in an inpatient setting, including immediately post-delivery, will be excluded from any inpatient per diem or global inpatient reimbursement. Only one LARC device is covered per inpatient stay.

Basic Contraceptive Implant Coding:

Please use the following procedure codes when filing claims:

The diagnosis coding will usually be selected from the Z30 (Encounter for contraceptive management series in ICD-10-CM:

The CPT procedure codes do not include the cost of supplies. Report supplies separately using an HCPCS code. If the specific J code does not exist, use the unclassified code (e.g. J3490) and indicate the NDC number in the shaded area above the code:

Basic IUD Coding:

Please use the following procedure codes when filing claims for IUDs:

Most IUD services will be linked to a diagnosis code from the Z30 series (Encounter for contraceptive management):

The CPT procedure codes do not include the cost of supplies. Report supplies separately using an HCPCS code. If the specific J code does not exist, use the unclassified code (e.g. J3490) and indicate the NDC number in the shaded area above the code:

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