Currentblue cross blue shield - michiganPolicy N/A

Enhanced Annual Physical Examination (Enhanced Benefit) - Coverage Criteria

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This policy governs coverage, payment, billing, and provider requirements for Medicare Plus Blue enhanced annual physical examinations (comprehensive preventive medicine evaluations) for Medicare Advantage PPO members. It affects Medicare Plus Blue individual and group PPO providers and enrolled members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyEnhanced Annual Physical Examination (Enhanced Benefit) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2026

Next Review DateN/A

Key ActionObtain a coverage determination from Medicare Plus Blue before providing noncovered items or services that the member may be asked to pay for.

SourceLink

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Currentblue cross blue shield - michiganPolicy N/A

Enhanced Annual Physical Examination (Enhanced Benefit) - Coverage Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - michigan policy alerts

Know when blue cross blue shield - michigan releases new policies or updates existing guidance.

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Policy Summary

Payerblue cross blue shield - michigan

PolicyEnhanced Annual Physical Examination (Enhanced Benefit) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2026

Next Review DateN/A

Key ActionObtain a coverage determination from Medicare Plus Blue before providing noncovered items or services that the member may be asked to pay for.

SourceLink

Coverage Criteria

Enhanced Annual Physical Examination - Coverage Criteria

Covered when ALL of the following are met

Member and plan eligibility: Member is covered under a Medicare Plus Blue individual or group PPO plan that includes this enhanced annual physical examination benefit; coverage is provided by Medicare Plus Blue even when Original Medicare has limited coverage

See policy for member cost share differences between individual and group plans

Service content: Service is an annual comprehensive preventive medicine evaluation including detailed history, family history, and a hands-on head-to-toe physical examination using inspection, palpation, auscultation and manual techniques across body systems

Additional cost share may apply for services that fall outside the scope of Original Medicare preventive screenings or covered immunizations

Frequency: Service is provided no more than once annuallyOnce annually

Provider and place of service: Service is provided by an eligible provider (M.D., D.O., or other practitioners) at a payable location (home, office, outpatient hospital, Rural Health Center, or Federally Qualified Health Center)

Bill on CMS-1500 or UB-04 per billing instructions

Original Medicare provides coverage for two specific preventive office visits: the one-time Welcome to Medicare (initial preventive physical examination) and the Annual Wellness Visit (AWV). Beyond those two visits, Original Medicare does not cover general annual physical examinations or preventive visits that are not the Welcome visit or AWV.

Annual physical examinations that are performed without relation to treatment or diagnosis for a specific illness, symptom, complaint, or injury are not considered medically necessary under Original Medicare. Such routine physicals fall outside the scope of Medicare’s medical necessity criteria unless they meet the specific Welcome or AWV visit definitions.

Coding and Frequency

Covered CPT/HCPCS CodesCPT | HCPCSCovered

99381	Initial comprehensive preventive medicine evaluation and management, new patient; infant (<1 year)
99382	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood (1–4 years)
99383	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood (5–11 years)
99384	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent (12–17 years)
99385	Initial comprehensive preventive medicine evaluation and management, new patient; 18–39 years
99386	Initial comprehensive preventive medicine evaluation and management, new patient; 40–64 years
99387	Initial comprehensive preventive medicine evaluation and management, new patient; 65 years and older
99391	Periodic comprehensive preventive medicine reevaluation and management, established patient; infant (<1 year)
99292	Periodic comprehensive preventive medicine reevaluation and management, established patient; early childhood (1–4 years)
99393	Periodic comprehensive preventive medicine reevaluation and management, established patient; late childhood (5–11 years)

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ICD-10ICD-10

Not Applicable

ICD-10 diagnosis restrictions: No restrictions listed

inv-06: Frequency limit — Once annually

Frequency limitOnce annually

ApplicabilityApplies to enhanced annual physical examinations under Medicare Plus Blue PPO plans

Related CPT/HCPCS restrictionSee payable CPT/HCPCS codes list (99381-99387, 99391-99397, 80050)

Provider/Place requirementCounts per member regardless of provider or payable location (home, office, outpatient hospital, RHC, FQHC)

Provider Actions and Billing Requirements

Prior Authorization

Coverage determination required for noncovered services

Obtain a coverage determination before providing noncovered items/services. If there is any question about coverage, seek a coverage determination from Medicare Plus Blue prior to delivering the item or service to the member to avoid financial liability.

Providers may be asked to collect payment for noncovered items/services only after a coverage determination has been obtained.
If a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share.

Billing Rule

Claims reporting and fee schedule verification

Verify reimbursement and fee schedules before billing. Use the Availity portal to find the Medicare Plus Blue PPO Enhanced Benefit Fee Schedule and confirm the plan's allowed amount; providers are paid the lesser of the allowed amount or the provider's charge, minus the member's cost share.

Background

Background: Original Medicare covers a limited set of preventive office visits — specifically the Welcome to Medicare exam (one-time within 12 months of Part B effective date) and the Annual Wellness Visit (AWV) (for beneficiaries with Part B >12 months who have not had a Welcome or AWV within the past 12 months). Outside these defined visits, Original Medicare does not cover routine annual physical examinations. Medicare Plus Blue provides an enhanced benefit to cover a comprehensive annual physical exam under plan terms despite Original Medicare’s limitations.

Definitions

inv-12: Medicare preventive visits — Annual Wellness Visit (AWV) / Welcome to Medicare

Original Medicare scopeOriginal Medicare covers only these two preventive visits and does not cover general annual physical examinations beyond that scope.

Relation to enhanced benefitMedicare Plus Blue uses Original Medicare as the base and may provide an enhanced annual physical exam benefit beyond Original Medicare's limited preventive visit coverage.

inv-13: Annual physical examination (enhanced benefit) — includes detailed history, family history and hands-on exam using inspection, palpation, etc.

DefinitionAnnual physical examination (enhanced benefit) — a detailed history, family history and a head-to-toe hands-on physical assessment using visual inspection, palpation, auscultation and manual examination of all body systems.

Coverage contextProvided as an enhanced benefit under Medicare Plus Blue PPO plans despite Original Medicare's limited coverage for routine annual physicals.