Guidance on How Pharmacists Can Enroll as Providers to Bill for Hormonal Contraception Services
Effective Oct. 1, 2023, the South Carolina Medicaid State Plan will be updated to allow South Carolina pharmacists to bill for hormonal contraception services in accordance with the Pharmacy Access Act and as described in this bulletin.
To be eligible for reimbursement for these services, pharmacists must complete a Healthy Connections Medicaid provider enrollment application. Pharmacists may apply on or after Sept. 18, 2023. Interested pharmacists are encouraged to apply on the providers page of the South Carolina Department of Health and Human Services’ (SCDHHS) website and enroll as an “individual pharmacist” under the provider type “other medical professional.” In addition to the standard enrollment information, pharmacists must provide information on the pharmacy or pharmacies where they will be providing this service. A training on completing this application and enrollment process is available on the SCDHHS website here.
Once enrolled, pharmacies will be able to bill for dates of service on or after Oct. 1, 2023, for Medicaid members. This includes members enrolled in the full-benefit Medicaid program and those enrolled in the Family Planning limited benefit program. Pharmacies will be reimbursed for the procedure and diagnosis codes listed below under the Healthy Connections Medicaid member’s medical benefit utilizing the CMS form 1500. These services will be reimbursed in parity with nurse practitioners and physician assistants at 80% of physician rates. The reimbursement rates for these services are available in the Base Physician Fee Schedule available on SCDHHS' website. Covered services and billing guidance will be added to the Physicians Services provider manual by Oct. 1, 2023.
Procedure Codes
| Code | Description |
|---|---|
| 99202 | New patient office visit 20 minutes |
| 99203 | New patient office visit 30-44 minutes |
| 99211 | Evaluation and management of established patients 5 minutes or less |
| 99212 | Evaluation and management of established patients 10-19 minutes |
| 99213 | Evaluation and management of established patients 20-29 minutes |
| 99214 | Evaluation and management of established patients 30-39 minutes |
| 96372 | Injection of drug/substance under skin or into muscle |
| 81025 | Urine pregnancy test |
Diagnosis Codes
| Oral Contraceptive | Contraceptive Patch |
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| Contraceptive Ring | Depo Shot |
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| General Counseling: Z30.09 |
South Carolina’s Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the coverage and reimbursement of services described in this bulletin for members enrolled in an MCO. Providers should direct any questions related to this bulletin to SCDHHS’ Office of Pharmacy Services at pharmacy@scdhhs.gov.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.