CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Health Services (Commercial Products)

Defines preventive services covered at no cost-share for Blue Cross Blue Shield Rhode Island commercial products, references USPSTF A/B, ACIP, HRSA and HRSA women's/infant/child guidance, and provides coding/claims processing and cost-sharing rules. Excludes Medicare Advantage (separate policy) and notes exceptions and provider billing guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services (Commercial Products)

Policy CodePolicy N/A

Change TypeClarified; one material clarification

Effective DateSep 23, 2010

Next Review DateN/A

Key ActionFile claims per the preventive services code grid and place the preventive diagnosis in the primary position to ensure no-cost-share processing.

SourceLink

POLICY UPDATE CHANGES

Restates that colorectal cancer screening age lowered to 45 for preventive coverage effective January 1, 2022.

Policy reiterates that updates to policy requirements are made annually in June and CPT/HCPCS updates are reflected in January.

4Referenced authoritative sources

TwoPreventive visits per year allowed for adults

1Max lag to implement new recommendations (years)

Coverage Summary

Defines preventive services covered at no cost-share for Blue Cross Blue Shield Rhode Island commercial products when delivered by an in-network provider per referenced authorities: USPSTF A/B, ACIP (CDC), and HRSA (including Women’s Preventive Services and Bright Futures/AAP). Coverage and coding guidance are provided to ensure correct no-cost-share processing. Note that this policy applies to Commercial Products and excludes Medicare Advantage (separate policy).

Effective for plan years beginning on or after September 23, 2010. Grandfathered plans are exempt and not subject to these preventive coverage requirements.

Key policy facts

Referenced authoritative sources4 (USPSTF A/B, ACIP/CDC, HRSA infants/children/Bright Futures, HRSA women)

Preventive visits per year allowed for adultsTwo

Maximum lag to implement new preventive recommendations1 year

Effective date (plan years beginning on or after)2010-09-23

Policy effective / document datesEffective policy reference shown; policy last reviewed 2024-11-01 (document published updates listed)

StatusCURRENT

Medical Necessity / Coverage Criteria

General Coverage Criteria

Preventive services are covered without cost share when delivered by an in-network provider and when they meet one of the referenced guideline sources:

ANY of the following

USPSTF A/B: Services with an A or B rating in the current U.S. Preventive Services Task Force (USPSTF) recommendations
ACIP/CDC Immunizations: Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP/CDC)
HRSA - Infants/Children/Adolescents: Preventive care and screenings for infants, children and adolescents as outlined by HRSA (including Bright Futures/AAP)
HRSA - Women's Preventive Services: Preventive care and screenings for women as outlined by HRSA Women's Preventive Services Guidelines

Timing for new recommendations: Plans must provide coverage for newly recommended preventive health services no later than one year after the recommendation release date1 year

Cost-sharing rule for in-network

Separate billing: If preventive service is billed separately from an office visit, plan may impose cost-sharing on the office visit but not on the preventive service
Primary intent rule: If preventive service is not billed separately, cost-sharing may not be imposed if the primary intent of the visit is preventive; if primary intent is non-preventive, cost-sharing may apply

Out-of-network: Plans may apply cost-sharing to preventive services delivered by out-of-network providers

Facility charges when preventive and non-preventive services combined: Facility charges will not have cost-sharing when one of the procedures performed is considered a preventive service (example: screening colonoscopy with endoscopy)

Colorectal screening age change: Effective January 1, 2022, colorectal cancer screening is covered as preventive without cost-sharing beginning at age 45Effective 01/01/2022

If during a screening colonoscopy a polyp is removed, that service and associated charges are without cost share; screening colonoscopy after an incomplete screening colonoscopy is without cost share

Women's preventive services: All HRSA Women's Preventive Services Guidelines (well-woman visits, HPV screening, domestic violence screening, contraception, etc.) are covered without cost-sharing effective August 2012Effective August 2012

Service frequency: If the guideline specifies frequency/method/setting, coverage must reflect the recommendation; if silent, plan may use reasonable medical management techniques to determine coverage limitations

Coding and Claims Processing Guidance

Coding and claims processing guidance (general)mixed

99401-99404	Preventive medicine counseling and risk factor reduction services - should not be filed on same date as preventive evaluation and management codes
99381-99397	Preventive evaluation and management office visit codes - include counseling; should not be filed same date as 99401-99404
modifier 33	Append to preventive pathology services for preventive colonoscopy and to counseling services and contraceptive injection when preventive
ICD-10 Z30.09	Use when contraceptive counseling is the ONLY service performed during the encounter

Use modifier 33 appended to preventive pathology services for preventive colonoscopy and to counseling services and contraceptive injections when those services are preventive. When contraceptive counseling is the only service performed, append ICD-10 Z30.09 to the claim.

Ensure the preventive diagnosis is placed in the primary diagnosis position on the claim to enable no-cost-share processing; if preventive services are billed separately from an office visit, cost-sharing may apply to the office visit but not the preventive service.

Effective January 1, 2022, colorectal cancer screening is covered as a preventive service beginning at age 45; follow the coding/grid guidance for claims processing related to this age change and related colonoscopy coding rules (including polyp removal and follow-up colonoscopies).

Provider Actions and Billing Rules

Documentation Required

File claims per coding grid and primary diagnosis position

Claims must be filed per the preventive services code grid and the preventive diagnosis should be listed in the primary position to ensure correct no-cost-share processing.

codes: []

Billing Rule

Use modifier 33 where applicable

Append modifier 33 to pathology services for preventive colonoscopy and to counseling services and contraceptive injections when preventive; use ICD-10 Z30.09 when contraceptive counseling is the only service performed.

modifier 33 - append to preventive pathology services for preventive colonoscopy; append to counseling services and contraceptive injection when preventive
ICD-10 Z30.09 - use when contraceptive counseling is the only service

Billing Rule

Preventive E/M and counseling billing separation

Preventive evaluation and management office visit codes (99381-99397) include counseling and should not be filed on the same date of service as preventive medicine counseling codes (99401-99404); the counseling codes represent separate face-to-face encounters.

Do not file preventive E/M codes (99381-99397) on same date as preventive counseling codes (99401-99404); counseling codes represent separate face-to-face encounters

Step Therapy

Updates and annual coding changes

Policy requirements are updated annually in June; CPT and HCPCS coding updates are reflected in January. Providers must follow the current code grid to ensure correct processing.

Denial Risk

Cost-share may be applied if billed incorrectly

If preventive services are billed improperly (for example, not separated when required or when the primary intent of the visit is documented as non-preventive), cost-sharing may be applied. Providers may contact Provider Relations or the Call Center to resolve claims that were misprocessed.

Cost-sharing may be applied when preventive services are not billed separately or when primary intent of the visit is non-preventive
Contact Provider Relations or Call Center to resolve misprocessed claims

Background

The Patient Protection and Affordable Care Act (PPACA) and the Interim Final Regulations (IFR) require that health plans cover certain preventive health services without cost-sharing when delivered by in-network providers. The IFR identifies four authoritative sources that define covered preventive services: USPSTF A/B recommendations, ACIP (CDC) immunization recommendations, HRSA guidelines for infants, children and adolescents (including Bright Futures/AAP), and HRSA Women’s Preventive Services Guidelines.

For plan years beginning on or after September 23, 2010, individual and group health plans must provide coverage for preventive health services without cost-sharing for in-network care. Plans must implement coverage for newly recommended preventive services no later than one year after the recommendation release date. Grandfathered plans are exempt from these preventive services requirements.

Preventive health services: services aimed at the prevention of disease or disability, including primary prevention (preventing occurrence of disease) and secondary prevention (mitigating consequences of an illness or condition), as defined by USPSTF, ACIP, and HRSA guidelines.

Revision History

Annual (June/January)maintenance

Annual maintenance schedule guidance: policy requirements updated annually in June; CPT/HCPCS coding updates are reflected in January. (Not a clinical change)

2022-01-01material_changeLatest

Material coding/claims processing update: colorectal cancer screening age lowered to 45 for preventive coverage effective January 1, 2022; see coding/grid guidance for claims processing (including modifier 33 guidance for preventive colonoscopy).