CurrentAlliance HealthPolicy 1A-2

Adult Preventive Medicine — Annual Health Assessment

Defines coverage, limitations, and requirements for an annual adult preventive medicine health assessment for North Carolina Medicaid beneficiaries aged 21 and older, including EPSDT exceptions for those under 21.

Policy Summary

PayerAlliance Health

PolicyAdult Preventive Medicine — Annual Health Assessment

Policy CodePolicy 1A-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify each Medicaid beneficiary's eligibility at every visit and, for beneficiaries under 21, document how the service meets EPSDT medical necessity when exceeding policy limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/365dfrequency allowed (21+)

21 yrsage threshold

appliesEPSDT exception

Z00.00, Z00.01ICD-10 examples

99385-99397CPT examples

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Covered — adult annual health assessment

Covered when ALL of the following are met

General medical necessity: The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of beneficiary's needs; can be safely furnished with no equally effective more conservative or less costly statewide alternative; and is not primarily for convenience of beneficiary, caretaker, or provider.

from Subsection 3.1

Frequency and age: Adult annual health assessment covered once per 365 days for Medicaid beneficiaries 21 years of age and older.once per 365 days; age >= 21

from Subsection 3.2.2

Coverage for adult annual health assessment

Covered when ALL of the following are met

Age and frequency: Beneficiary is 21 years of age or older and receives no more than one annual health assessment per 365 days.>=21 years; 1 per 365 days

Assessment excluded from the 22-visit legislated limit (Subsection 5.3.a–b).

Medical criteria listed in Section 3.0 are met and recipient does not have an illness or specific health care need that results in a definitive medical diagnosis with medical decision-making and initiation of treatment.Section 3.0 criteria

If Section 3.0 criteria are not met, assessment is not covered (see 4.2.2).

Medicaid shall not cover the procedure, product, or service when any of the following apply: the beneficiary does not meet the eligibility requirements in Section 2.0; the beneficiary does not meet the criteria listed in Section 3.0; the service duplicates another provider's procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

For beneficiaries 21 years of age and older, an adult annual health assessment is limited to one per 365 days. The annual health assessment is excluded from the legislated 22‑visit per year limit. When billing, note that injectable medications and ancillary laboratory or radiology studies are the only CPT codes that may be billed separately with an annual health assessment, and an annual health assessment and a separate office visit cannot be billed on the same date of service.

The adult annual health assessment is not covered when the medical criteria in Section 3.0 are not met. Coverage is also denied when the recipient has an illness or specific health care need that results in a definitive medical diagnosis requiring medical decision‑making and initiation of treatment; in such cases the assessment criteria do not apply and the annual assessment is not payable.

An annual health assessment is considered not medically necessary (NMN) when the medical criteria in Section 3.0 are not satisfied, or when the beneficiary presents with an illness that requires medical decision‑making and initiation of treatment. In these situations the service does not meet the policy’s preventive assessment criteria and should be denied as NMN.

Coding, Frequency, and Billing Rules

Covered CPT CodesCPTCovered

99385	CPT Code(s) = 99385.
99386	CPT Code(s) = 99386.
99387	CPT Code(s) = 99387.
99395	CPT Code(s) = 99395.
99396	CPT Code(s) = 99396.
99397	CPT Code(s) = 99397.

ICD-10 CodesICD-10

Z00.00	ICD-10- Code(s) = Z00.00.
Z00.01	ICD-10- Code(s) = Z00.01.

inv-09: Frequency

FrequencyOnce per 365 days

Billing limitationAnnual health assessment and an office visit cannot be billed on the same date of service

Separately billable when assessment billedOnly injectable medications and ancillary laboratory and radiology studies are separately billable

inv-10: Assessment frequency

Assessment frequency (age 21+)One annual health assessment per 365 days for Medicaid beneficiaries 21 years of age and older

Legislated visit limit exclusionThe annual health assessment is not included in the legislated 22-visit limit per year

Billing conflictAn annual health assessment and an office visit cannot be billed on the same date of service

Provider Requirements, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Authorization Required (EPSDT note)

Prior approval requirements remain in effect for services that require prior authorization. For beneficiaries under 21 years of age, EPSDT does not eliminate any prior approval requirement — providers must still obtain prior approval when the service, product, or procedure requires it.

If a service requires prior approval, the beneficiary's age (<21) does not waive that requirement.
See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional instructions: https://www.nctracks.nc.gov and https://medicaid.ncdhhs.gov/

Documentation Required

Eligibility Verification and EPSDT Documentation

Verify each beneficiary's Medicaid eligibility at every visit. For beneficiaries under 21, document how the requested service meets EPSDT medical necessity criteria to justify any exceedance of standard policy limits.

Verify eligibility at each encounter.
For <21 beneficiaries, document EPSDT justification showing how the service corrects or ameliorates a defect, illness, or condition, and why limits should be exceeded.

Documentation Required

Claims and Documentation Requirements

Claims must follow NCTracks guidance and Medicaid billing rules. Report diagnosis and procedure codes to the highest level of specificity that supports medical necessity and follow the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and clinical coverage policies.

Use professional (CMS-1500/837P) claim type unless otherwise directed; institutional claims follow National Uniform Billing Guidelines.
Report ICD-10-CM and PCS codes to the highest specificity; current edition must be used.
Reference NC Medicaid fee schedules and bulletins for reimbursement rules.

Billing Rule

Modifiers and Code Reporting / Billing Units

Follow applicable modifier guidelines and report appropriate procedure codes that determine billing units. Failure to report correct modifiers or procedure codes may result in incorrect reimbursement or claim denials.

Apply modifiers per payer and coding guidance.
Report the procedure code(s) that determine the billing unit(s) for services rendered.

Denial Risk

Denial Triggers

Denial risk exists when statutory or policy criteria are not met. Claims may be denied if the beneficiary fails to meet Section 2.0 eligibility, Section 3.0 medical necessity criteria, the service duplicates another provider's service, or the service is experimental/investigational.

Denials likely if beneficiary does not meet Section 2.0 eligibility requirements.
Denials likely if Section 3.0 medical necessity criteria are not met.
Services duplicating another provider's procedure, or that are experimental/investigational, may be denied.

OpenPayer

Adult Preventive Medicine — Annual Health Assessment

Coverage Criteria for Adult Annual Health Assessment

Coding, Frequency, and Billing Rules

Provider Requirements, Prior Authorization, and Billing Guidance

Background

Definitions