CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

preventive_services_policy

Defines preventive services covered without member cost-share for Blue Cross Blue Shield Rhode Island Commercial products, referencing USPSTF A/B, ACIP, HRSA, and related guidelines; includes coding, billing, cost-sharing rules, and service limitations for claims processing.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policypreventive_services_policy

Policy CodePolicy N/A

Change Typeclarified; added

Effective DateSep 23, 2010

Next Review Date

Key ActionWhen a recommendation specifies frequency, method, treatment or setting, coverage must reflect those details; if guideline is silent, use reasonable medical management techniques.

SourceLink

POLICY UPDATE CHANGES

Policy updates are made annually in June; CPT/HCPCS coding updates are reflected in January grid.

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

4Reference Authorities for Coverage

2Preventive Visits Allowed per Year (adults)

2010PPACA Preventive Requirement Effective

Coverage Summary

Defines preventive services covered without member cost-share for Blue Cross Blue Shield Rhode Island Commercial products. Coverage applies to services recommended by the USPSTF (A/B), immunizations recommended by ACIP (CDC), and preventive care/screenings per HRSA (children, adolescents, and women). Per policy, these services are covered without member cost-sharing when criteria are met and claims are filed according to the coding and billing guidance. Effective: 01/01/2024; Last review: 01/01/2025.

Medical-Necessity / Coverage Criteria

General Coverage Criteria for Preventive Health Services

Preventive services are covered without cost share when they meet recommendations from specified authorities; coverage follows guideline-specified frequency, method, and setting when provided.

Authority-based recommendation: Service is a preventive health service that has an A or B USPSTF recommendation OR immunizations recommended by ACIP (CDC) OR preventive care and screenings for infants, children and adolescents per HRSA/Bright Futures/AAP OR preventive care and screenings for women per HRSA Women's Preventive Services Guidelines
References the four IFR sources for defining preventive services
Provider network requirement: Service is delivered by an in-network provider to be covered without cost-sharing (preventive services delivered by out-of-network providers may have cost-sharing)
IFR and policy specify in-network coverage without cost share; out-of-network may be subject to cost-sharing
Guideline specifics: If the recommendation or guideline specifies frequency, method, treatment, or setting, coverage must reflect those specifics; if the guideline is silent, the plan may use reasonable medical management techniques
Policy requires following guideline details when present; allows reasonable medical management when silent

Timing for New Recommendations

Timing for New Recommendations: Plans must provide coverage for newly recommended preventive health services no later than one year after the recommendation release date

Applies to newly recommended preventive services per policy/IFR

"Preventive Health Services" are defined as services that have an USPSTF A or B rating, immunizations recommended by the ACIP (CDC), preventive care and screenings for infants, children, and adolescents per HRSA/Bright Futures, and preventive care and screenings for women per HRSA Women’s Preventive Services Guidelines.

Coding and Claim Filing Notes

Coding / Claim Filing Notes (preventive services)mixed

99401-99404	Preventive medicine counseling and risk factor reduction services — should not be filed on same date as preventive E/M codes
99381-99397	Preventive medicine comprehensive initial and periodic examinations — include counseling; not to be billed same day as 99401-99404
modifier 33	Append to pathology services for preventive colonoscopy and to counseling services and to injections filed with contraceptive as preventive services
ICD-10: Z30.09	Use on claim when contraceptive counseling is the ONLY service performed during the encounter

The policy notes a material change: Colorectal cancer screening is covered without cost sharing beginning at age 45 effective Jan 1, 2022; coding and claims processing guidance for this update are reflected in the January code grid and the policy's coding section. Claims for follow-up colonoscopy after incomplete screening or polyp removal should be identified so they are processed as preventive and without member cost share.

Provider Actions & Billing Rules

Documentation Required

Follow guideline-specified frequency/method when present

When a recommendation specifies frequency, method, treatment or setting, coverage must reflect those details; if guideline is silent, use reasonable medical management techniques.

Billing Rule

File claims according to preventive coding grid and primary diagnosis position

Claims must be filed per the attached preventive services code grid and with any diagnosis noted in the primary position on the claim to ensure no cost share applies.

use primary diagnosis to ensure no cost share

Billing Rule

Modifier 33 and ICD-10 use for specific preventive services

Append modifier 33 to specified pathology and counseling services; append ICD-10 Z30.09 when contraceptive counseling is the only service.

modifier 33
Z30.09

Billing Rule

Preventive E/M and counseling billing exclusion

Do not file preventive E/M codes (99381-99397) on the same date of service as preventive medicine counseling codes (99401-99404).

99381-99397
99401-99404

Prior Authorization

Prior authorization generally not required

Prior authorization is generally not required for preventive services; exceptions are noted elsewhere in the policy (not specified in this document).

Billing Rule

Colorectal screening age and claim handling

Colorectal cancer screening is covered without cost sharing beginning at age 45 (effective Jan 1, 2022); if follow-up colonoscopy after incomplete screening or polyp removal occurs, related services are without cost share and claims should be identified to be processed as preventive.

Age 45 effective Jan 1, 2022
Identify follow-up colonoscopy claims as preventive to ensure no member cost share

Denial Risk

Out-of-network preventive services may be subject to cost-sharing

Preventive services delivered by out-of-network providers may have cost-sharing applied; institutional facility charges may be subject to cost-sharing when preventive and nonpreventive services are performed at the same time except where specific guidance applies (e.g., screening colonoscopy example).

Background

The PPACA (Patient Protection and Affordable Care Act) and subsequent Interim Final Regulations (IFR) require that, for plan years beginning on or after September 23, 2010, individual and group health plans provide coverage for preventive health services without cost-sharing when delivered by in-network providers. The IFR specifies that services recommended by the USPSTF (A/B), ACIP, and HRSA (children’s and women’s preventive service guidelines) must be covered without cost-sharing. Grandfathered plans are exempt from these requirements. Plans must adopt newly recommended preventive services no later than one year after the recommendation release date, and when guidelines specify frequency/method/setting, coverage must reflect those specifics; when silent, plans may use reasonable medical management techniques.

OpenPayer

preventive_services_policy

Coverage Summary

Medical-Necessity / Coverage Criteria

Coding and Claim Filing Notes

Provider Actions & Billing Rules

Background

Revision History