Currentblue cross blue shield - michiganPolicy N/A

Screening Papanicolaou tests, pelvic and clinical breast examinations

Policy governing coverage, payment, frequency, and billing for screening Papanicolaou (Pap) tests, screening pelvic examinations and clinical breast examinations for Medicare Plus Blue Group PPO members; aligns benefits with Original Medicare and applies to specified Medicare Plus Blue Group PPO plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyScreening Papanicolaou tests, pelvic and clinical breast examinations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill on CMS 1500 or 837; report CPT/HCPCS and diagnosis codes to highest specificity and submit to the local BCBS plan using required electronic billing procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once annuallyroutine screening frequency (unless high risk or recent abnormal)

Original Medicarecoverage level

waived for select plansage/diagnosis exception

appliesmember cost-share

Coverage and Payment Criteria

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Screening Pap/pelvic/clinical breast coverage criteria

Coverage and payment conditions

Services are covered subject to the conditions below.

Frequency/Eligibility

Routine screening: covered every 24 months consistent with Original Medicare.every 24 months
Annual screening: allowed if the beneficiary is considered high risk or is of childbearing age with an abnormal Pap test within the previous 3 years.once annually when high risk or childbearing age with abnormal Pap within prior 3 years
Medicare Plus Blue Group PPO plans may provide annual coverage for screening Pap/pelvic/clinical breast examinations for members on select plans; effective Jan 1, 2014 BCBSM no longer offers enhanced benefits for these services and coverage aligns with Original Medicare.

Eligible provider and payable location requirements are consistent with Original Medicare.

Follow Original Medicare provider and location rules.

Age and diagnosis restrictions may be waived for select Medicare Plus Blue Group PPO plans.

See plan-specific benefit design to determine if age restriction is waived.

Reimbursement: Medicare Plus Blue Group PPO plan's maximum payment amounts are consistent with Original Medicare. Provider will be paid the lesser of the allowed amount or the provider's charge minus the member's cost-share; balance billing is not permitted.

Member cost-sharing: members are responsible for applicable copayment, coinsurance or deductible; collect cost-share at time of service when possible. If member elects noncovered service, member is responsible for full charge; verify benefits via web-DENIS or CAREN.

Billing: bill services on the CMS 1500 (8/05) form or 837 equivalent; report CPT/HCPCS and diagnosis codes to highest specificity and include NPI; submit to the member's local BCBS plan and follow Medicare Advantage PPO billing requirements.

Codes and Frequency

CPT/HCPCS codingmixed

No codes listed

Frequency

Routine screening frequencyOnce annually (consistent with Original Medicare); exceptions permit annual screening for beneficiaries considered high risk or childbearing age with recent abnormal Pap as allowed by Original Medicare

Original Medicare alignmentEligibility, payable location, and frequency/limitations are consistent with Original Medicare; Medicare Plus Blue Group PPO provides at least the same level of benefit

Age/diagnosis exceptionsAge restriction may be waived for select Medicare Plus Blue Group PPO plans

Provider and location payment conditionsEligible provider and payable location payment conditions follow Original Medicare rules

Plan noteAs of policy effective date, maximum payment amounts are consistent with Original Medicare and plan-specific enhanced benefits may not apply

Billing and Submission Instructions

Billing Rule

Billing and submission instructions

Bill services on the CMS 1500 (8/05) claim form or 837 equivalent; follow Medicare Advantage PPO unique billing requirements; report CPT/HCPCS and diagnosis codes to the highest level of specificity; include your National Provider Identifier on all claims; submit claims to your local BCBS plan; use electronic billing per the BCBSM EDI Professional 837/835 Companion Document (Michigan providers) or contact your local BCBS plan if outside Michigan.

Bill on CMS 1500 (8/05) or 837 equivalent
Use Medicare Advantage PPO unique billing requirements
Report CPT/HCPCS and diagnosis codes to highest specificity
Report National Provider Identifier on all claims
Submit claims to local BCBS plan
Use electronic billing (see BCBSM EDI Professional 837/835 Companion Document for Michigan providers; out-of-state providers contact local BCBS)

Definitions

Screening Pap test

DefinitionScreening Papanicolaou test: routine exfoliative cytology test (Papanicolaou test) including sample collection and physician interpretation provided for early detection of cervical cancer

ScopeIncludes collection of cellular sample and laboratory interpretation to detect significant abnormal cell changes that may precede cervical cancer

PurposeEarly diagnosis and treatment of abnormal cell changes to reduce progression to cervical cancer and related morbidity and mortality

Screening pelvic and clinical breast examination

DefinitionScreening pelvic examination: preventive pelvic exam for adult women to detect pre-cancers, genital cancers, infections, STDs, reproductive system abnormalities and include a clinical breast examination

Clinical breast examinationIncluded as part of the screening pelvic examination to detect breast masses, lumps and signs of breast cancer

Scope and purposeAids detection and prevention of genital and breast pathologies and supports overall lower genitourinary tract health; payment conditions align with Original Medicare