This policy describes coverage and payment for the Annual Physical Examination as an enhanced benefit under Wellmark Advantage Health Plans (WMAHP) for Medicare Advantage members in Iowa and South Dakota. Unlike Original Medicare — which covers the Welcome to Medicare exam and the Annual Wellness Visit but does not cover Annual Physical Examinations — WMAHP provides coverage for a comprehensive, hands-on preventive visit that includes detailed medical and family history and a head-to-toe physical exam using visual inspection, palpation, auscultation, and manual examination to assess overall health and identify potential abnormalities [[1],[2],[0]].
Coverage is available to WMAHP members effective 01/01/2022 and is administered according to WMAHP policy terms. Payment is made per the WMAHP Enhanced Benefit Fee Schedule, which represents payment in full; providers may not balance-bill members for the difference between the allowed amount and the provider charge [[4]].
Key administrative rules: the benefit is payable once annually; eligible providers include MD, DO, and Practitioners; payable locations are Home, Office, and Outpatient hospital; and billed CPT/HCPCS must match allowed codes (for example 99381–99387, 99391–99397, G0468, 80050). Claims must report CPT/HCPCS and diagnosis codes to the highest level of specificity and comply with the policy’s diagnosis restrictions. The visit itself has a $0.00 member cost share, though non-covered services provided during the visit are the member’s financial responsibility [[3],[6],[5]].
Billing guidance and member verification: bill on CMS-1500 (02/12) for applicable sites (FQHC, CAH, and RHC bill on UB-04), report NPI and taxonomy on claims, and submit claims electronically to Wellmark Advantage Health Plan, Station 1E238 PO Box 9291, Des Moines, IA 50306. To verify member eligibility, benefits, and cost share, providers should use the Wellmark Advantage Health Plans secure website or call Provider Inquiry at 1-855-716-2556 (TTY: 711) [[6],[5]].