11.09.02s, Gender-Affirming Interventions

REQUIREMENTS: Billing Team: - By 12/15/2025: Update billing system to REPLACE HCPCS code S0189 with J1073 for all testosterone pellet implant (75 mg) claims effective 01/01/2026. This change applies to gender-affirming hormone replacement therapy claims. - Verify that claim scrubbers and adjudication rules no longer route S0189 claims as of 01/01/2026; implement blocking or auto-correction logic. - For New York members only (effective 04/29/2026): Implement mandatory medical necessity review process for gender-affirming interventions using the "Services Subject to Medical Necessity Review for New York Members" attachment. Route all New York claims for pre-billing compliance review. Providers: - Ensure all prescriptions for testosterone pellet implants use the updated J1073 code on orders placed after 01/01/2026. - For New York patients: Providers must ensure documentation meets the revised medical necessity requirements outlined in the new attachment (e.g., letter of recommendation from behavioral health provider with master's degree, documentation of gender dysphoria diagnosis, Tanner staging if applicable). Consequences: - Claims billed with obsolete code S0189 after 01/01/2026 will likely be denied or rejected during system validation. - New York claims lacking required medical necessity documentation will be denied per the updated policy attachment.