CHIP Reproductive Services Coverage Update

Pennsylvania CHIP is implementing updated billing and reimbursement requirements for medically necessary abortion services in response to a recent judicial decision and implementation guidance from the Pennsylvania Department of Human Services (DHS).

Federal funding for abortion services remains limited to cases related to rape, incest, miscarriage, or when the mother's life is endangered. Medically necessary abortion services that do not meet these federally funded criteria should be billed as outlined below. “Medically Necessary” means a service or benefit that is compensable under CHIP if it meets any one of the following standards:

• The service, item, procedure, or level of care will, or is reasonably expected to, prevent the onset of an illness, condition, injury, or disability.
• The service, item, procedure, or level of care will, or is reasonably expected to, reduce, or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.
• The service, item, procedure, or level of care will assist the enrollee to achieve or maintain maximum functional capacity in performing daily activities, considering both the functional capacity of the enrollee and those functional capacities that are appropriate for enrollees of the same age.

Providers should review the following billing and documentation requirements for abortion services provided to CHIP enrollees.

Billing Requirements Beginning Dec. 1, 2026

The DHS has identified the U3 (other) modifier for use for claims and encounters for medically necessary abortion services that do not qualify for federal funding. Submit claims using the following guidelines:

• Continue submitting the G7 modifier for federally funded abortion services and use the applicable modifier
  • U1: Mother's life endangered
  • U2: Pregnancy resulting from rape or incest
  • U4: Miscarriage
• For other medically necessary abortion services (do not count for federal funding), submit claims using the U3 modifier. The G7 modifier is not required.

The following procedure codes are applicable to abortion services billed under these requirements: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, and S0199.

Documentation Requirements

For claims submitted with U1, U2, or U4 modifiers, providers must submit and retain the required physician certification and enrollee statements through Availity Essentials or with a paper claim. Documentation is not required for non-federally funded, medically necessary abortion claims submitted with the U3 modifier.