11.09.02r, Gender-Affirming Interventions

By 07/01/2025 (or immediately if already past): Billing team must update claim validation rules to recognize HCPCS code J1954 (revised narrative) and all listed gender-affirming intervention codes (J1050, J1071, J1072, J1073, J1380, C1789, C1813, C2622, D5919, D5925, D5929, D7996) as medically necessary when proper documentation is present. For all gender-affirming claims: (1) Require behavioral health provider letter meeting all specified guidelines (master's degree minimum, documented diagnosis, treatment duration, compliance assessment) before processing; (2) Verify member meets medical necessity criteria per policy (persistent gender dysphoria/incongruence, appropriate Tanner stage for puberty suppressants, age 18+ for mastectomy unless documented exception); (3) Flag for denial any oral or self-administered hormone claims as non-covered per medical benefit exclusion; (4) Update encounter templates to require ICD-10 codes F64.0-F64.9, F64.A, or Z87.8901-Z87.8909 for proper coding. Clinical staff must educate providers on required documentation standards. Review claims denials related to missing behavioral health letters and resubmit when documentation is obtained.