Preventive Health Services Coverage
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
Colorectal Cancer Screening
Colorectal cancer screening specifics
Effective January 1, 2022, coverage begins at age 45; follow the Coding/Commercial grid for claims processing guidance.
Ensure claims are filed per the Preventive Services for Commercial grid so services are processed as preventive.
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:
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
| 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) |
| 33 | Modifier 33 — Preventive Services |
| Z30.09 | ICD-10 — Encounter for initial prescription of contraceptives (used when contraceptive counseling is the only service) |
Provider Actions & Billing Guidance
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.
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.
- The grid reflects annual CPT/HCPCS updates (January) and policy updates (June).
Claims Filing and Potential Denial Risk
Claims filing and potential denial risk: file claims per the attached grid and apply the specified modifiers and diagnosis codes. Failure to file with the required primary diagnosis, modifiers, or to follow the grid instructions may result in denial or member cost-sharing.
- Append modifier 33 to pathology services for a preventive colonoscopy.
- Append modifier 33 to counseling services and include ICD-10 code Z30.09 when contraceptive counseling is the only service provided.
- For injections filed with a contraceptive, append modifier 33.
- If a preventive service is not billed as specified (including primary diagnosis position), the claim may be denied or processed with member cost share.
Provider Action Items
Provider action items: ensure billing aligns with cost-sharing rules and coding guidance in this policy. For in-network encounters, determine whether the preventive service is billed separately or bundled with an office visit to assess applicability of member cost-sharing. For out-of-network and institutional scenarios, be aware different cost-sharing rules may apply.
- Determine primary intent of the visit when preventive services occur with other care; billing determines cost-sharing.
- For screening colonoscopy with polypectomy or follow-up procedures within six months, submit claims noting preventive status to avoid member cost share; contact Provider Relations or the Call Center if a claim is mistakenly assessed.
- Local participating providers: some covered codes may not be separately reimbursed — review the grid and payer instructions before billing.
Billing Documentation Notes
Billing documentation notes: follow modifier and coding guidance to ensure preventive processing.
- Append modifier 33 (Preventive Services) to pathology services for a preventive colonoscopy.
- Append modifier 33 to an injection filed with a contraceptive and to counseling services when contraceptive counseling is the only service provided; include ICD-10 Z30.09 in that case.
- Do not file Preventive Evaluation & Management visit codes on the same date as preventive medicine counseling codes (99401-99404); CPT indicates preventive visit codes (99381-99397) already include counseling as appropriate.
Denial / Cost-sharing Triggers
Denial / Cost-sharing Triggers — watch for situations that may trigger member cost-sharing or claim denial.
- Services delivered by out-of-network providers may be subject to cost-sharing.
- Services not listed in the four federal preventive sources or not billed per the grid may be denied or have cost-sharing applied.
- Failure to append required modifiers or to list the required primary diagnosis can lead to denial or application of member cost share.
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
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