CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Health Services Coverage

This policy governs coverage and coding for preventive health services for Commercial Products, specifying which services are covered without member cost-share and how claims should be processed for in-network and out-of-network providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Health Services Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateSep 18, 2025

Key ActionFile claims per the Commercial Preventive Services code grid and append required modifiers (for example, Modifier 33 when applicable) to ensure preventive services are processed without member cost-share.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

no cost shareCovered in-network

twoAdult preventive visits/year

within 6 monthsFollow-up colonoscopy

1 yearNew recommendations covered by

01/01/2024Policy effective

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

Colorectal Cancer Screening

Colorectal cancer screening specifics

Age threshold: Colorectal cancer screening is covered as a preventive health service without cost sharing beginning at age 45.age >=45

Effective January 1, 2022, coverage begins at age 45; follow the Coding/Commercial grid for claims processing guidance.

Polypectomy during screening colonoscopy: If a polyp is removed during a screening colonoscopy, the polypectomy and associated charges are paid without member cost share.

Ensure claims are filed per the Preventive Services for Commercial grid so services are processed as preventive.

Follow-up screening colonoscopy timeframe: A follow-up colonoscopy performed after an incomplete screening colonoscopy or as a screening follow-up will be considered a preventive service when performed within six months of the initial screening colonoscopy.follow-up within 6 months

If a follow-up claim incorrectly applies member cost share, contact the Call Center (401-274-4848) or Provider Relations (ProviderRelations@bcbsri.org) to have the claim reprocessed without member cost share.

Covered Preventive Services Conditions

Covered preventive services must meet the following:

Commercial plan filing and cost-sharing: For Commercial products listed on the Preventive Services for Commercial code grid, the services are covered without copayment/coinsurance/deductible when filed as specified on the grid with any diagnosis on the grid placed in the primary position on the claim.

Services not identified by the PPACA as preventive are covered under the applicable benefit section of the member's Subscriber Agreement and may be subject to cost sharing.

Plans may deny coverage for services that are not listed in the four federal sources that define preventive health services: USPSTF A or B recommendations, ACIP immunization recommendations, HRSA guidelines for preventive care and screenings for infants, children, and adolescents, and HRSA women’s preventive services. The IFR explicitly permits plans to provide additional preventive services but also allows denial of coverage for services outside these referenced sources.

Grandfathered plans are exempt from the preventive services requirements described in this policy and are not required to follow the IFR preventive services mandates. For services that are not identified by the PPACA as preventive, coverage will follow the enrollee’s Subscriber Agreement and may be subject to member cost-sharing (copayments, deductibles, coinsurance) per the applicable benefit section.

Not applicable.

Coding & Modifiers

Coding and Modifier GuidanceCPT | Modifier

33	Modifier 33 — Preventive Services (append to pathology services for preventive colonoscopy and certain injections)
99381-99397	Preventive Medicine initial and periodic comprehensive preventive medicine examination codes (include counseling)
99401-99404	Preventive medicine counseling and risk factor reduction services (separate face-to-face encounters)

Preventive modifiers and diagnosis codesModifier | ICD-10Covered

33	Modifier 33 — Preventive Services
Z30.09	ICD-10 — Encounter for initial prescription of contraceptives (used when contraceptive counseling is the only service)

Colorectal cancer screening age threshold — beginning at age 45

Age thresholdColorectal cancer screening is covered as a preventive health service beginning at age 45 (effective January 1, 2022).

Follow-up windowA follow-up screening colonoscopy is considered preventive (no cost share) when performed within 6 months of the initial screening colonoscopy.

Polypectomy during screeningIf a polyp is removed during a screening colonoscopy, the polypectomy and associated charges are paid without cost share.

Claims assistance if cost share appliedIf a follow-up claim incorrectly applies member cost share, contact Call Center (401-274-4848) or Provider Relations (ProviderRelations@bcbsri.org) to reprocess the claim as preventive.

Provider Actions & Billing Guidance

Prior Authorization

Prior Authorization Generally Not Required

Prior authorization is generally not required for preventive services under this policy. Exceptions are noted elsewhere in the policy and on the attached code grid — providers should confirm any service-specific prior authorization requirements before rendering care.

Billing Rule

Follow Commercial Preventive Services Code Grid

Follow the Commercial Preventive Services code grid for claims filing and coding. The grid lists covered preventive services and the required billing instructions; claims must be filed exactly as specified on the grid with the diagnosis listed in the primary position on the claim to ensure preventive processing.

Commercial Preventive Services code grid determines correct filing and processing rules.
Claims must be filed as noted on the attached grid with the diagnosis listed in the primary position on the claim.

Background

Preventive health services encompass both primary prevention (interventions to prevent the initial occurrence of disease) and secondary prevention (measures to detect disease early and mitigate its consequences). Coverage under this policy is tied to authoritative guideline sources: services with an A or B USPSTF rating, ACIP-recommended immunizations, HRSA-supported preventive care and screening recommendations for infants, children, and adolescents, and HRSA women’s preventive services. When delivered by an in-network provider and falling within these sources, such services are covered without member cost-sharing in accordance with the IFR and related guidance.

Definitions

Services with A or B USPSTF rating, ACIP-recommended immunizations, HRSA child/adolescent preventive care, and HRSA women's preventive services as defined in IFR

Authoritative sourcesServices with an A or B USPSTF rating; immunizations recommended by ACIP (CDC); HRSA-recommended preventive care and screenings for infants, children, and adolescents; HRSA-recommended preventive care and screenings for women as defined in the IFR.

Scope of coverageSection V of the IFR lists preventive health services that must be covered without cost-sharing when delivered by an in‑network provider; HHS maintains an updated list on HealthCare.gov.

Plans may provide additional servicesNothing in the IFR prevents a plan from covering preventive services beyond those sources; however plans may deny coverage for services not in the four sources listed.

Preventive health services — primary healthcare aimed at preventing disease or disability

DefinitionPreventive health services constitute primary healthcare aimed at preventing disease or disability, including services proven effective in avoiding disease occurrence (primary prevention) and mitigating consequences of illness (secondary prevention).