CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Health Services Coverage (Commercial)

Defines coverage, coding, cost-sharing, and claims processing rules for preventive health services for Commercial products, and explains alignment with federal requirements and recommended sources; affects in-network and out-of-network providers and covered members under Commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services Coverage (Commercial)

Policy CodePolicy N/A

Change TypeAnnual update / coding refresh

Effective DateJan 1, 2024

Next Review DateJan 1, 2024

Key ActionAppend modifier 33 where applicable and file claims per the attached coding grid to ensure preventive services are processed without cost-sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No cost shareNo cost share

TwoPreventive visits/yr

45Colorectal screening age

AnnualPolicy update cadence

Since 9/23/2010Effective baseline

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Preventive Services

Covered Preventive Services

Covered when services meet recommendations from one of the authoritative sources and are delivered by an in-network provider:

Primary coverage rule: Service is a preventive service recommended with a grade A or B by the U.S. Preventive Services Task Force OR listed by the Advisory Committee on Immunization Practices (ACIP) for immunizations OR included in HRSA guidelines for infants, children and adolescents (including AAP Bright Futures) OR included in HRSA women’s preventive services guidelines.

Coverage must reflect the frequency, method, treatment, or setting when specified by the source; if the source is silent the plan may apply reasonable medical management techniques.

Provider/network: Services delivered by in-network providers are covered without cost-sharing; out-of-network delivery may be subject to cost-sharing per plan terms.

Section V of the IFR requires coverage without cost-sharing when delivered by an in-network provider; plans may provide additional preventive coverage but may deny services not contained in the four authoritative sources.

Implementation timeline: Coverage for newly recommended preventive health services must be provided no later than one year after the release date of the recommendation.<= 1 year

Claims filing requirement: Claims for preventive services must be filed according to the guidelines in this policy (use attached coding grid and place the appropriate diagnosis in the primary position) to ensure correct processing and recognition of no cost-share for in-network services.

See attached coding grid and filing instructions in the policy for specifics.

Commercial Preventive Services

Covered when meeting federal preventive service recommendations and filing/coverage rules

Commercial Preventive Services Coverage: Services recommended by USPSTF (A or B), ACIP, HRSA (including AAP Bright Futures), and HRSA women’s preventive services guidelines are covered for commercial members without copayment, coinsurance, or deductible when delivered in-network.implementation <= 1 year after recommendation release

Claims must be filed per the attached coding grid with the appropriate diagnosis in the primary position to ensure correct member benefit processing.

Services that are not included in the four authoritative sources referenced in this policy (USPSTF A/B recommendations, ACIP immunization guidance, HRSA child/adolescent preventive guidelines including AAP Bright Futures, and HRSA women’s preventive services) may be excluded from coverage as preventive services. Plans may impose cost-sharing for services that exceed or fall outside those sources; for example, coverage for treatments initiated as a result of a preventive screening (such as cholesterol medication after a screening) may be subject to the plan’s cost-sharing rules.

Services that are not identified by the PPACA as preventive health services are covered according to the member’s Subscriber Agreement or other benefit documents. Such services may be subject to cost-sharing (copayments, deductibles, coinsurance) in accordance with the applicable benefit provisions; grandfathered plans remain exempt from the preventive services requirements described in this policy.

Medical Criteria: Not applicable. There are no separate medical necessity criteria specified in this policy for preventive services.

This policy is provided for informational purposes and is not a guarantee of payment. Benefits and eligibility are determined by the member’s Subscriber Agreement or employer agreement, which supersede this policy. Services determined to be not medically necessary may be denied or billed to the member only if the member was informed and agreed in writing in advance.

Coding, Age Thresholds, and Update Timing

Coding notes and preventive service codesCPT | Modifier

99401-99404	Preventive medicine counseling and risk factor reduction services (do not file on same date as preventive E/M)
99381	Preventive medicine, initial comprehensive preventive medicine examination (example given)
33	Modifier 33 (Preventive Services) — append to pathology services for a preventive colonoscopy and other preventive services as applicable

Preventive Coding NotesICD-10 | ModifierCovered

Z30.09	ICD-10 code for other contraceptive counseling
33	Modifier 33 (Preventive Services) to be appended to counseling services when contraceptive counseling is the only service

Colorectal cancer screening age threshold

Colorectal cancer screening age threshold>= 45 years (preventive coverage begins at age 45, effective Jan 1, 2022)

Effective date for thresholdEffective January 1, 2022

Cost-sharing implicationCovered as a preventive health service without cost share when delivered by an in-network provider

Policy and coding update timing

Policy update cadencePolicy requirements updated annually in June

Coding update timingAll applicable CPT and HCPCS annual coding updates are reflected in January

Provider Filing, Authorization, and Billing Requirements

Prior Authorization

Prior authorization is generally not required for preventive services. Exceptions are noted elsewhere in this policy and in the attached coding grid; providers should check the grid and any service-specific attachments for services that require prior authorization.

Prior authorization typically not required for preventive services
See attached coding grid for any services that do require prior authorization

Billing Rule

Attachment‑Driven Authorization and Claims Guidance

The attached preventive services coding grid and related attachments drive correct claims processing. Claims for preventive services must be filed using the codes and diagnosis codes listed on the attachment, with the appropriate diagnosis in the primary position. Incorrect or non‑attachment filing may trigger processing issues or denials.

Background and Policy Purpose

Preventive health services encompass both primary prevention (services intended to prevent the occurrence of disease) and secondary prevention (services intended to detect disease early and mitigate its consequences). Coverage under this policy aligns with recommendations from authoritative sources — specifically USPSTF A/B recommendations, ACIP immunization guidance, HRSA pediatric and women’s preventive guidelines (including AAP Bright Futures) — and services meeting those recommendations are covered consistent with the frequency and conditions specified by the source.

Definitions and Authoritative Sources

Preventive health services — definition

Primary preventionServices proven effective in avoiding the occurrence of a disease or disability (to prevent disease)

Secondary preventionServices proven effective in mitigating the consequences of an illness or condition (to reduce impact/complications)

ScopePreventive health services are provided without cost share when delivered by an in-network provider per PPACA requirements (effective for plan years beginning on or after Sept 23, 2010)

Authoritative sources for required coverage

USPSTFU.S. Preventive Services Task Force (A or B recommendations)

ACIPAdvisory Committee on Immunization Practices (CDC) — immunization recommendations

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services Coverage (Commercial)

Policy CodePolicy N/A

Change TypeAnnual update / coding refresh

Effective DateJan 1, 2024

Next Review DateJan 1, 2024

Key ActionAppend modifier 33 where applicable and file claims per the attached coding grid to ensure preventive services are processed without cost-sharing.

SourceLink

On This Page

Implementation noteClaims processing and coding grid should reflect January coding updates and June policy changes

File claims using the attached coding grid and include the specified primary diagnosis code
Follow any special filing instructions in service‑specific attachments

Denial Risk

Denial Risk for Non‑Referenced Preventive Services

Plans may deny coverage for services identified as preventive only if those services are not among the four referenced authoritative sources (USPSTF A/B, ACIP, HRSA including Bright Futures/AAP, HRSA Women’s Preventive Services). Services outside these sources may be treated as non‑preventive and be subject to plan coverage rules and cost‑sharing.

Covered preventive services follow USPSTF A/B, ACIP, HRSA (including Bright Futures/AAP) and HRSA Women’s guidelines
Services not appearing in those sources may be denied as preventive and may be subject to cost‑sharing or standard coverage determinations

Documentation Required

Claim Filing Requirements

Claims must be filed with the attachment’s specified codes and the appropriate diagnosis in the primary position. Failure to use the attached codes or to place the required diagnosis in the primary position may result in processing delays or denials.

Use the attached grid codes and place the required diagnosis code in the primary position on the claim
Incorrect claim filing can trigger claim processing issues or denials

Billing Rule

Claims Filing and Modifier Guidance

Billing and modifier rules: append modifier 33 (Preventive Services) where applicable (for example, to applicable pathology or counseling services and to preventive injections when required). When contraceptive counseling is the only service performed, append modifier 33 and include ICD‑10 code Z30.09 on the claim. Bill preventive service CPT codes separately from an office visit when appropriate per CPT guidance.

Append modifier 33 to eligible preventive services (e.g., pathology for preventive colonoscopy, counseling when applicable)
When contraceptive counseling is the only service, append modifier 33 and ICD‑10 Z30.09
Do not file preventive E/M visit codes on the same date as CPT 99401‑99404 preventive counseling codes

HRSA child/adolescentHRSA guidelines for preventive care and screenings for infants, children, and adolescents (including Bright Futures/AAP)

Preventive services scope

Primary prevention servicesServices aimed at preventing the occurrence of disease (examples: USPSTF A/B recommended screenings and immunizations per ACIP)

Secondary prevention servicesServices aimed at mitigating the consequences of illness or condition (e.g., screenings that enable early intervention)

Guideline alignmentServices must follow USPSTF A/B, ACIP, HRSA (children/adolescents and women) and AAP Bright Futures guidance; plans may implement frequency/method/setting as specified by the source

Grandfathered plans

Grandfathered plans exemptionGrandfathered plans are exempt from the preventive services requirements outlined in this policy

Coverage applicabilityMembers in non-grandfathered commercial plans receive preventive services per the authoritative sources without cost share when delivered in-network

Plan-specific rulesServices not listed in the four authoritative sources may be covered or denied according to the plan and Subscriber Agreement