- To facilitate reporting, submit electronic claims with the family planning indicator in professional claims at Loop 2400/SV1 12 set to "Y". Bill the FP modifier on paper claims, but continue to report the pricing modifier in the first position.
Paper claims should be submitted to:
Claims Processing Department
P.O. Box 7115
London, KY 40742
- The Pennsylvania Department of Human Services' (DHS) sterilization consent form (MA31) (PDF) must accompany all claims for reimbursement for sterilization services. The form must be completed correctly in accordance with the instructions. The claim and consent forms will be retained by Keystone First.
- DPW's physician certification for an abortion (MA3) (PDF) and the recipient statement form (MA368 (PDF) or MA369 (PDF) must accompany all claims for reimbursement for termination of pregnancy services. The physician certification for an abortion and recipient statement form must be submitted in accordance with the instructions on the certification/form. The claim form, physician certification for an abortion, and recipient statement form will be retained by Keystone First.