CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive health services policy

Defines preventive health services covered without cost share for Blue Cross Blue Shield - Rhode Island Commercial products, aligning coverage to USPSTF A/B, ACIP, HRSA, and HRSA women's guidelines; includes coding, cost-sharing rules, prior authorization exceptions, and billing notes to ensure correct claims processing.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive health services policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionFile claims with the applicable preventive diagnosis code in the primary position to ensure processing under the preventive benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this update.

A/BUSPSTF rating basis for covered services

>=45Colorectal screening starting age

2Allowed preventive visits per adult per year

Coverage Summary

Scope: Defines preventive health services covered without cost share for Blue Cross Blue Shield - Rhode Island Commercial products, aligned to recommendations from USPSTF (A/B), ACIP (CDC), HRSA (including Women’s Preventive Services) and Bright Futures/American Academy of Pediatrics. Effective date: 01/01/2024. Last review: 05/23/2025. Note: under PPACA plans for plan years beginning on or after September 23, 2010 must provide coverage for preventive services and adopt newly recommended preventive services within one year of release per federal guidance.

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Medical Necessity / Coverage Criteria

General Coverage Criteria

Preventive services are covered without cost share when delivered by in‑network providers and when they meet one of the specified guideline sources; coverage follows the recommendations below:

ANY of the following

Services that have an A or B rating in the current recommendations of the U.S. Preventive Services Task Force (USPSTF)
Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC)
Preventive care and screenings for infants, children, and adolescents as outlined by HRSA and Bright Futures/American Academy of Pediatrics
Preventive care and screenings for women as outlined in HRSA Women's Preventive Services Guidelines

Coverage timing

Coverage for newly recommended preventive health services is provided no later than one year after the release date of the recommendation
If a guideline specifies frequency/method/setting, coverage reflects those recommendations; if silent, plan may use reasonable medical management techniques to determine coverage limitations

Cost-Sharing Rules (In-network vs Out-of-network / Visit intent)

Rules determining when cost-sharing may be applied:

ALL of the following

In-network preventive services delivered and billed as preventive are covered without cost-sharing
If preventive service is billed separately from an office visit, the plan may impose cost-sharing on the office visit but not on the preventive service
If preventive service is not billed separately, plan looks to primary intent of visit: if primary intent is preventive, no cost-sharing on the office visit; if primary intent is non-preventive, cost-sharing may be imposed on the office visit even if a preventive service is provided
Out-of-network preventive services may have cost-sharing applied, including to the office visit and to the service

Colorectal Cancer Screening Specifics

Special rules for colorectal screening and colonoscopy-related services:

Colorectal cancer screening covered without cost sharing beginning at age 45Effective Jan 1, 2022

Effective January 1, 2022: coverage begins at age 45

If during a screening colonoscopy a polyp is removed, associated charges are without cost share

A screening colonoscopy performed after an incomplete screening colonoscopy is without cost share

A follow-up colonoscopy will be considered preventive when performed within six months of the initial screening colonoscopy; if a follow-up claim is incorrectly applying member cost share, provider may contact Call Center or Provider Relations to have the claim reprocessed without member cost sharewithin 6 months

Contact Call Center 401-274-4848 or ProviderRelations@bcbsri.org to reprocess claims incorrectly applying member cost share

Service Limitations

Limits that apply based on member contract/calendar year:

Service limitations are based on calendar/plan year depending on the member's contract

Two preventive visits per year for adults are allowed (e.g., member changes PCP or to allow woman to see PCP and GYN)2 per calendar/plan year

Prior Authorization

General prior authorization statement and exceptions:

Prior authorization is generally not required; exceptions are noted in this policy (no specific PA codes listed)

Provider Actions & Billing Rules

Documentation Required

File claims with preventive coding and primary diagnosis in primary position

Claims must be filed according to the policy coding grid with the applicable preventive diagnosis code in the primary position to ensure processing under the preventive benefit. (No specific codes listed.)

Billing Rule

Do not file preventive E/M on same date as preventive counseling codes

Preventive Evaluation and Management office visit codes should not be filed on the same date of service as preventive medicine counseling codes per CPT instructions.

99381-99397
99401-99404

Billing Rule

Append modifier 33 for specified preventive services

Append modifier 33 to counseling services and to pathology services for preventive colonoscopy and to an injection filed with contraceptive to identify preventive services.

Billing Rule

Use ICD-10 code Z30.09 when contraceptive counseling is sole service

Report ICD-10 code Z30.09 and append modifier 33 when contraceptive counseling is the only service provided during the encounter.

Z30.09
33

Denial Risk

Member cost-share may apply based on visit intent or out-of-network status

In-network preventive services billed as preventive are covered without cost share; however, cost-sharing may apply if the primary intent of the visit is non-preventive or if the service is delivered by an out-of-network provider.

Documentation Required

Contact for reprocessing follow-up colonoscopy claims

If a follow-up colonoscopy performed within six months of an initial screening colonoscopy is incorrectly applying member cost share, contact Call Center 401-274-4848 or ProviderRelations@bcbsri.org to have the claim reprocessed as preventive.

Background

Background: This policy implements the PPACA preventive services requirements (effective for plan years beginning on or after September 23, 2010). Plans must follow recommendations from the U.S. Preventive Services Task Force (USPSTF) A/B recommendations, immunization recommendations from the Advisory Committee on Immunization Practices (ACIP), CDC, preventive care and screening guidance for infants, children, and adolescents from HRSA and Bright Futures/American Academy of Pediatrics, and preventive care for women from HRSA Women’s Preventive Services Guidelines. Plans are required to adopt newly recommended preventive health services no later than one year after the recommendation is released.

Definitions: Preventive health services — services aimed at the prevention of disease or disability, including primary prevention and secondary prevention as described by USPSTF, ACIP, and HRSA guidelines.

OpenPayer

Preventive health services policy

Coverage Summary

Medical Necessity / Coverage Criteria

Coding

Provider Actions & Billing Rules

Background

Revision History