NCTracks
New Edits for Family Planning Modifier
Beginning August 1, 2016, two new edits will be implemented for MAFDN-covered services, also known as Family Planning Medicaid.
The first edit will deny outpatient clinic claims and lab claims for MAFDN-covered services when the service has been rendered to a beneficiary with MAFDN coverage and the code is not billed with the FP modifier.
• EOB 01659 (Edit 02608) - CLAIM DENIED. PROCEDURE CODE MUST BILL WITH FP MODIFIER
The second edit will deny outpatient clinic claims when no procedure code is billed or the procedure code is not covered by Family Planning Medicaid (MAFDN).
• EOB 02609 (Edit 02609) - CLAIM DENIED. FAMILY PLANNING PROCEDURE CODE MUST BE PRESENT ON FAMILY PLANNING CLAIM OR PROCEDURE CODE NOT COVERED BY MAFDN
When billing covered revenue codes for MAFDN beneficiaries, a procedure code will be required on the claim. If no procedure code is found on the claim or the procedure code is non-covered by MAFDN, the claim will deny. Providers can refer to Clinical Coverage Policy 1E-7 for Family Planning Services for a list of covered revenue and procedure codes.
The Division of Medical Assistance (DMA) payer is the only payer affected by this implementation. These edits are applicable to the MAFDN Benefit Plan and MAFDN beneficiaries. There will be no claims reprocessing as a result of this new update.
For a complete list of benefit plans mapped to DMA eligibility coverage codes, providers can refer to Provider Policies, Manuals, Guidelines and Forms found on the NCTracks Provider Portal.