CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Health Services for Commercial Products

Defines coverage and coding guidelines for preventive health services for Blue Cross Blue Shield of Rhode Island commercial products, including cost-sharing rules, billing/coding instructions, and sources of covered preventive recommendations (USPSTF, ACIP, HRSA, HRSA women's services).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services for Commercial Products

Policy CodePolicy N/A

Change TypeClarified / Administrative

Effective DateSep 23, 2010

Next Review DateN/A

Key ActionFile claims according to the Preventive Services for Commercial code grid with the diagnosis in the primary position to ensure coverage without cost share.

SourceLink

POLICY UPDATE CHANGES

Colorectal cancer screening covered without cost share beginning at age 45 effective January 1, 2022.

Added guidance that a follow-up colonoscopy within six months of initial screening is considered preventive and should be paid without cost share.

Annual updates to policy requirements occur in June; CPT/HCPCS coding updates reflected in January grid.

4Accepted preventive sources (USPSTF/ACIP/HRSA/HRSA women's)

>=45Colorectal screening start age (years)

2Adult preventive visits allowed per year (specific circumstances)

This policy defines coverage and coding guidelines for preventive health services for Blue Cross Blue Shield of Rhode Island commercial products. Coverage without member cost share applies to services that meet the preventive definition from one of the four accepted sources: USPSTF A/B recommendations, ACIP immunizations, HRSA pediatric preventive care, and HRSA women's preventive services, when delivered by an in-network provider and filed according to the policy coding grid.

Key thresholds and stats: colorectal cancer screening is covered without cost share beginning at age >= 45 (effective January 1, 2022); the policy recognizes 4 accepted preventive sources; and allows up to 2 adult preventive visits per year in specified circumstances. Grandfathered plans are exempt from these preventive requirements, and Medicare Advantage members are subject to a separate preventive services policy.

Key thresholds and quick facts

Colorectal cancer screening age>= 45 years (effective January 1, 2022)

Accepted preventive sourcesUSPSTF A/B; ACIP; HRSA pediatric; HRSA women's (4)

Adult preventive visits allowed per yearUp to 2 in specified circumstances (PCP change or both PCP and GYN visits)

Medical-Necessity Criteria

General coverage rule for preventive services

Preventive services are covered without cost share when ALL of the following apply:

General preventive coverage

Accepted preventive sources: Service is a preventive health service as defined by one of the accepted sources (USPSTF A/B; ACIP immunizations; HRSA pediatric preventive care; HRSA women's preventive services).
References: USPSTF A/B; ACIP; HRSA pediatric; HRSA women's guidelines.
In-network delivery: Service is delivered by an in-network provider (for no cost share).
Cost-sharing rules for in-network providers per IFR; see exceptions for billing of mixed visits.
Claims filed per coding grid: Claims are filed according to the coding guidelines in the policy (use the Preventive Services for Commercial code grid, append modifier 33 where noted, list diagnosis in primary position).
See coding grid and coding notes for January/annual updates.

Exceptions and special rules (cost-sharing and related)

Coverage without cost share may NOT apply in these situations:

Exceptions and special rules

Out-of-network providers: Service delivered by an out-of-network provider (plans may impose cost-sharing).
Plans may apply cost-sharing to preventive services delivered out-of-network.
Preventive not billed separately: Preventive service not billed separately from an office visit where the primary intent of the visit is non-preventive (cost-sharing may be imposed per IFR guidance).
IFR instructs plans to look to primary intent of visit when services not billed separately.
Services outside accepted sources: Preventive services beyond the four accepted sources may have cost-sharing applied if the plan chooses to impose it. (Plans may provide more generous coverage but may impose cost-sharing on services not in the four sources.)

Colorectal screening special rules

Colorectal screening coverage specifics:

Colorectal screening rules

Age and effective date: Colorectal cancer screening covered without cost share beginning at age 45 (effective January 1, 2022).>= 45 years
See coding grid for claim processing guidelines and policy effective date for colorectal screening change.
Polyp removal: If a polyp is removed during a screening colonoscopy, that service and associated charges are paid without cost share.
Incomplete to screening: A screening colonoscopy performed after an incomplete screening colonoscopy is paid without cost share.

Coding

Preventive Services Coding Grid (Commercial)mixed

No codes listed

Modifier guidanceModifier

33	Append modifier 33 (Preventive Services) to pathology services for a preventive colonoscopy and an injection filed with a contraceptive; also append to counseling services as noted in policy.

Contraceptive counseling ICD-10 guidanceICD-10

Z30.09

Use ICD-10 code Z30.09 on the claim when contraceptive counseling is the ONLY service performed during the encounter.

See the Preventive Services for Commercial code grid for detailed claim processing and coding guidelines; annual CPT/HCPCS updates are reflected in the January grid. The attached grid contains the specific codes, modifiers, and claim instructions needed to process preventive claims correctly.

To ensure services are processed with no member cost share, claims must be filed per the code grid and have the appropriate diagnosis noted in the primary position on the claim as required by the policy and provider guidance.

Provider Actions

Documentation Required

File claims according to code grid and primary diagnosis position

Claims must be filed using the Preventive Services for Commercial code grid and the diagnosis listed in the primary position on the claim to ensure processing as a preventive service with no member cost share.

Billing Rule

Append modifier 33 for specific services

Append modifier 33 (Preventive Services) as directed for preventive colonoscopy pathology, certain injections filed with a contraceptive, and for counseling services when applicable.

Pathology services for a preventive colonoscopy
Injections filed with a contraceptive
Counseling services when preventive (per policy notes)

Billing Rule

Preventive E/M and counseling not on same date

Preventive E/M (comprehensive preventive medicine) codes should not be filed on the same date of service as preventive medicine counseling codes; the counseling codes represent separate face-to-face encounters.

99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404

Denial Risk

Cost-share may be applied if billed incorrectly

If preventive services are not billed separately or the claim coding/diagnosis does not comply with the policy/code grid, the claim may be processed under non-preventive benefits or member cost-sharing may be applied.

Prior Authorization

Prior authorization generally not required

Prior authorization is generally not required for preventive services under this policy; any exceptions are noted in the policy text (no specific prior authorization rules are listed).

Documentation Required

Correct follow-up colonoscopy processing

If a follow-up screening colonoscopy performed within six months of the initial screening is processed with member cost share, contact the Call Center or Provider Relations so the claim can be identified and reprocessed as a preventive service with no member cost share.

Background

This policy implements the Patient Protection and Affordable Care Act (PPACA) preventive services requirements (including IFR guidance) for commercial products. For plan years beginning on or after September 23, 2010, individual and group health plans must provide coverage for preventive health services; when delivered by in-network providers, many preventive services are covered without cost sharing.

Preventive services are defined by the IFR using four sources: USPSTF A/B recommendations, ACIP immunizations, HRSA pediatric preventive care, and HRSA women's preventive services. Coverage follows the frequency, method, and setting recommendations from those sources when specified. Grandfathered plans are exempt from these preventive requirements, and Medicare Advantage members are subject to a separate preventive services policy.

Preventive health services: services aimed at the prevention of disease or mitigation of disease consequences as defined by USPSTF A/B recommendations, ACIP immunizations, HRSA pediatric guidelines, and HRSA women's preventive services. Coverage without cost share applies when these services are delivered by an in-network provider and billed according to the policy coding guidance.

Revision History

Effective January 1, 2022coverage_change

Colorectal cancer screening covered without cost share beginning at age 45 (effective January 1, 2022). See coding grid within the Coding Section for claims processing guidelines.

coding_guidance

See Preventive Services for Commercial code grid for claim processing guidelines; applicable CPT and HCPCS annual coding updates are reflected in the January code grid and policy updates are made annually in June.

coding_detail

Append modifier 33 (Preventive Services) to pathology services for a preventive colonoscopy and to counseling services as noted; use ICD-10 code Z30.09 when contraceptive counseling is the only service performed.

coverage_clarification

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

operational_contact

For a screening follow-up colonoscopy performed within six months of the initial screening (considered preventive), if member cost share is applied contact the Call Center at 401-274-4848 or Provider Relations at ProviderRelations@bcbsri.org to ensure the claim is reprocessed with no member cost share.

Administrative/operational timingadministrative_timing

Administrative timing guidance: policy requirements updated annually in June; CPT/HCPCS coding updates reflected on the January Preventive Services for Commercial grid. (Administrative timing guidance only; not material.)

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