CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Health Services for Commercial Products

Defines coverage of preventive health services for Blue Cross Blue Shield of Rhode Island Commercial products, describing that services recommended by USPSTF A/B, ACIP, HRSA (including Bright Futures and women's preventive services) are covered without member cost-share when delivered in-network and provides coding, billing and cost-sharing rules and filing guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services for Commercial Products

Policy CodePolicy N/A

Change TypeClarified; material update (colorectal screening age)

Effective DateSep 23, 2010

Next Review DateN/A

Key ActionFile claims according to the attached code grid; append modifier 33 for preventive services where instructed and use ICD-10 Z30.09 when contraceptive counseling is the only service.

SourceLink

POLICY UPDATE CHANGES

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

Guidance that preventive services recommended by USPSTF A/B, ACIP, HRSA (Bright Futures and women's preventive services) are covered without cost share.

4Accepted Reference Sources

2Preventive visits allowed per year (adults)

45Colorectal screening starting age

Scope: This policy defines coverage of preventive health services for Blue Cross Blue Shield of Rhode Island Commercial products. Preventive services recommended by the USPSTF (A or B), ACIP/CDC, and HRSA (including Bright Futures and HRSA Women’s Preventive Services) are covered without member cost-sharing when delivered by an in-network provider. Grandfathered plans are exempt from these preventive coverage requirements. The policy also provides coding, billing, and cost-sharing filing guidance to ensure correct claims processing.

Overview: Coverage for newly recommended preventive services must be implemented no later than one year (≤ 1 year) from the recommendation release date. The policy includes specific rules for office visits that include preventive services, cost-sharing rules for out-of-network care, and colorectal screening guidance (see coding/grid for claim filing instructions).

Key Thresholds and Reference Sources

New preventive recommendation adoption window≤ 1 year from recommendation release

Colorectal cancer screening age≥ 45 years (effective 2022-01-01)

Preventive visits allowed per year (adults)2

Accepted Reference SourcesUSPSTF, ACIP, HRSA, AAP

Coding and Filing Guidance

Coding and Filing Guidance (general)mixed

99401-99404	Preventive medicine counseling and risk factor reduction services (should not be filed same date as preventive E/M codes 99381-99397)
99381-99397	Preventive evaluation and management office visit codes (include counseling; should not be filed same date as 99401-99404)
Z30.09	ICD-10 code to append when contraceptive counseling is the ONLY service performed
modifier 33	Append to preventive services (e.g., pathology for preventive colonoscopy, counseling services, injections with contraceptive)

Coding and filing notes: Do not file Preventive Evaluation and Management office visit codes 99381-99397 on the same date of service as preventive medicine counseling codes 99401-99404; CPT instructions state that 99381-99397 include counseling, and 99401-99404 represent separate face-to-face counseling encounters.

When instructed, append modifier 33 (Preventive Services) to applicable preventive services (for example, pathology services for a preventive colonoscopy, counseling services, or injections filed with contraceptive claims). If contraceptive counseling is the only service performed during the encounter, include ICD-10 code Z30.09 on the claim.

Administrative/process guidance: Follow the policy’s attached code grid and annual coding updates for processing guidance; updates to policy requirements are made annually (code/CPT/HCPCS updates reflected on the Preventive Services for Commercial code grid). Prior authorization is generally not required for preventive services unless otherwise noted.

Provider Actions & Billing Impact

Documentation Required

Use recommended coding and modifiers

File claims according to the attached code grid. Append modifier 33 for preventive services where instructed and use ICD-10 code Z30.09 when contraceptive counseling is the only service performed.

modifier 33
Z30.09
99381-99397
99401-99404

Billing Rule

Preventive E/M vs Counseling billing

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

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.

Denial Risk

Out-of-network cost-sharing risk

If preventive services are delivered by out-of-network providers, plans may apply cost-sharing. Verify a provider's network status to avoid member cost-share.

Documentation Required

Contact for incorrect member cost-share

If a preventive follow-up colonoscopy claim is processed with member cost share applied, contact the Call Center or Provider Relations to ensure the claim is identified and processed without member cost share.

Call Center 401-274-4848
ProviderRelations@bcbsri.org

Background & Evidence

Background: The Patient Protection and Affordable Care Act (PPACA) and the implementing Interim Final Regulations (IFR) require that, for plan years beginning on or after September 23, 2010, group and individual health plans provide coverage for preventive health services without cost-sharing when delivered by in-network providers, based on specified sources (USPSTF A/B recommendations, ACIP immunizations, HRSA pediatric/Bright Futures and women’s preventive services). Grandfathered plans are exempt from these preventive service requirements.

Adoption timeline and updates: Plans must provide coverage for newly recommended preventive health services no later than one year after the recommendation is released. The policy notes that colorectal cancer screening to begin at age 45 as a preventive service without cost-sharing became effective January 1, 2022, and directs providers to the coding section/grid for claims processing guidance related to that change.

Evidence and Guidance Sources

Regulatory basisPatient Protection and Affordable Care Act and Interim Final Regulations (HHS/Treasury/Labor)

Guideline sourcesUSPSTF, ACIP (CDC), HRSA (Bright Futures, women's preventive services), AAP

Preventive health services (definition)

Preventive health services: Services aimed at prevention of disease or mitigating consequences of illness; includes services with USPSTF A/B recommendations, ACIP immunizations, HRSA pediatric and women's preventive services.

Revision History

2022-01-01material

Material change: Colorectal cancer screening covered without cost sharing beginning at age 45 effective January 1, 2022. See Coding section for claims processing guidance and grid updates; polyp removal and follow-up colonoscopies related to screening are also without cost share.

2010-09-23clarifiedLatest

Clarification: Preventive services recommended by USPSTF (A/B), ACIP (CDC), and HRSA (Bright Futures and women's preventive services) are covered without member cost share when delivered in-network; plans must adopt newly recommended services no later than one year after recommendation release and follow the attached coding/grid guidance.