Preventive Health Services Coverage (Commercial Products)
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Defines which preventive services are covered without cost share for Blue Cross Blue Shield - Rhode Island commercial products, outlines billing/coding rules and cost-sharing exceptions, and describes applicable guideline sources and implementation timing. Affects in-network commercial plan members and participating providers submitting claims.
No material clinical or coverage changes in this revision.
Covered Preventive Services & Criteria
Cost-Sharing Rules and Exceptions
Cost-sharing and billing exceptions:
Facility charges are not subject to cost-sharing when a preventive procedure is performed in an institutional setting. Plans may impose cost-sharing on services provided in excess of the referenced sources and on treatment resulting from a preventive service (e.g., medication).
Plans determine coverage for preventive services based on the four federal reference sources cited in the IFR. Covered preventive services are those that meet one or more of the following criteria: have an A or B USPSTF recommendation, are immunizations recommended by ACIP, are included in HRSA-supported comprehensive guidelines for infants/children/adolescents, or are included in HRSA-supported comprehensive guidelines for women. The IFR notes that the HHS-maintained website lists the most current preventive services and that a plan may deny coverage for preventive services that are not contained in these four referenced sources.
Services that are not identified by the PPACA (IFR) as preventive health services may still be covered by the plan, but such coverage is governed by the member's Subscriber Agreement and applicable benefit sections. In those cases, standard cost-sharing (for example, copayments, coinsurance, and deductibles) may apply according to the member’s benefit terms.
Grandfathered health plans are exempt from the PPACA preventive services requirements and therefore are not required to follow the IFR preventive coverage mandates. Where State law provides more generous preventive coverage than federal requirements, the State mandate controls and supersedes federal minimums to the extent specified by law.
Coding Guidance & Code Lists
| 33 | Modifier 33 — Preventive Services (append to pathology services for a preventive colonoscopy and certain injections) |
| 99381-99397 | Preventive medicine evaluation and management codes (include counseling; should not be filed same date as 99401-99404) |
| 99401-99404 | Preventive medicine counseling and risk factor reduction services (separate face-to-face encounters) |
| 33 | Modifier 33 (Preventive Services) |
| Z30.09 | ICD-10: Encounter for contraceptive counseling or initial prescription when it is the only service (use when contraceptive counseling is the ONLY service performed) |
Provider Billing, Claims & Authorization Actions
Prior Authorization
Prior authorization is generally not required; exceptions are noted in this policy.
Out-of-Network Cost-Sharing Risk
For out-of-network providers: Plans may apply cost-sharing requirements to preventive health services delivered by an out-of-network provider; this includes cost-sharing attached to the office visit as well as the actual services provided. For in-network institutional providers, facility charges will not be applied when a preventive procedure is performed alongside nonpreventive procedures (e.g., screening colonoscopy performed with endoscopy). Plans may impose cost-sharing on any treatment given as a result of a preventive service (for example, medication started because of a screening result).
- Out-of-network preventive services may be subject to member cost-sharing.
- Facility charges: no cost-sharing when a preventive procedure is one of the services performed.
Claims Filing and Documentation
Claims for the Commercial Preventive Services listed on the Preventive Services grid must be filed as noted on the attached grid with any diagnosis noted on the grid in the primary position on the claim. Failure to list the required diagnosis in the primary position may result in denial or application of cost-sharing.
- File claims exactly as specified on the Preventive Services grid.
- Diagnosis listed on the grid must be in the primary position to qualify for preventive coverage.
Claims submission and coding notes
File claims per the Preventive Services coding grid. Append modifier 33 (Preventive Services) where required — for example, to pathology services for a preventive colonoscopy, to an injection filed with a contraceptive, and to counseling services when contraceptive counseling is the only service performed (also include ICD-10 Z30.09 in that instance). Updates to coding requirements are reflected annually; ensure CPT/HCPCS updates on the Preventive Services grid are followed.
- Append modifier 33 to pathology services for a preventive colonoscopy.
- Append modifier 33 to an injection filed with a contraceptive.
- When contraceptive counseling is the only service, append modifier 33 and ICD-10 code Z30.09.
Claims filing and modifier requirements
Failure to file claims with the required diagnosis in the primary position or to append required modifiers (e.g., 33) may result in claim denials or application of member cost-sharing. For local participating providers, some covered preventive codes may not be separately reimbursed — confirm reimbursement rules before billing.
- Missing modifier 33 or incorrect diagnosis positioning can trigger denial or cost-sharing.
- Some codes may be covered but not separately reimbursed for local participating providers.
Background and Scope
Preventive health services encompass interventions intended to prevent disease occurrence and to reduce the impact of existing disease. This includes primary prevention (measures taken to prevent the initial development of a condition) and secondary prevention (activities such as screening and early detection that mitigate consequences and improve outcomes). Covered services follow authoritative guideline sources (USPSTF, ACIP, HRSA) and are implemented as described in those sources.
Definitions
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