Preventive Health Services Coverage (Commercial)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Defines which preventive services are covered without member cost share for Commercial Products and provides coding and claims-processing guidance for in-network and out-of-network scenarios.
No material clinical or coverage changes in this revision.
Coverage Criteria
Basic Coverage Criteria
Covered when delivered by an in-network provider and included in one of the referenced authoritative sources:
Coverage for newly recommended preventive services is implemented no later than one year after the recommendation release date; plans may provide additional preventive coverage beyond these sources.
Colorectal Cancer Screening
Special rules for colorectal cancer screening and colonoscopy-related services
Effective January 1, 2022; see coding grid for claims processing guidance.
File claims per coding guidance so services are processed as preventive.
If a follow-up claim posts with member cost share, contact the Call Center (401-274-4848) or Provider Relations (ProviderRelations@bcbsri.org) to correct processing.
Commercial Preventive Services Coverage
Covered when ALL of the following are met
Coverage must follow those guideline recommendations; HHS maintains current lists.
Grandfathered plans are exempt from these preventive service requirements.
Incorrect filing or omitting required modifiers/diagnosis positions may affect processing; see attached code grid for exact claim instructions.
Plans may deny coverage for preventive services that are not included in the four authoritative sources referenced by the IFR: USPSTF A/B recommendations, CDC/ACIP immunization guidance, HRSA guidelines for infants/children/adolescents, and HRSA women’s preventive services. The IFR explicitly permits plans to limit no-cost preventive coverage to services listed in these sources when delivered by an in-network provider.
Services that are not identified by the PPACA (IFR) as preventive health services are processed under the member’s regular benefit provisions in the Subscriber Agreement and may be subject to applicable cost-sharing (copayments, deductibles, coinsurance). Note that grandfathered plans are exempt from the preventive services requirements described in this policy.
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, certificate, or employer agreement, which supersede this policy. Services determined to be not medically necessary or otherwise non-covered may not be billed to the member unless the member has been informed and has provided written agreement to pay in advance.
Coding and Billing Guidance
| 33 | Modifier 33 — Preventive Services (apply to pathology for preventive colonoscopy and contraceptive injection) |
| 99381-99397 | Preventive medicine comprehensive visits |
| 99401-99404 | Preventive medicine counseling / risk factor reduction (separate encounter) |
| Modifier 33 | Preventive Services modifier — append to specified preventive services (e.g., pathology for preventive colonoscopy, counseling services) |
| ICD-10 Z30.09 | Contraceptive counseling — append when contraceptive counseling is the only service performed |
Provider Actions and Claim Filing
Prior Authorization
Prior authorization is generally not required; exceptions are noted in this policy.
Filing and Benefit Determination
The Commercial Preventive Services listed in the attached code grid are covered without copayment, coinsurance, or deductibles when filed as indicated. To ensure correct claims processing of these preventive services, claims must be filed per the attached grid with any diagnosis listed on the grid in the primary position on the claim. Failure to file claims as noted on the attached code grid may result in denials or application of member cost-sharing.
- File claims using the codes and diagnosis pointers shown on the Preventive Services for Commercial Code Grid.
- Services not identified by PPACA as preventive should be filed under the applicable benefit; cost share may apply.
Coding and Documentation Notes
Follow coding and documentation guidelines to ensure preventive services are processed without member cost share.
- Append modifier 33 (Preventive Services) to specified services (including pathology services for a preventive colonoscopy, injections filed with a contraceptive, and counseling services when applicable).
- When contraceptive counseling is the ONLY service performed during the encounter, append modifier 33 to the counseling code and include ICD-10 code Z30.09 in the claim.
- Preventive Evaluation and Management (E/M) visit codes should not be filed on the same date of service as preventive medicine counseling codes (99401-99404).
- Local participating providers: some covered codes may not be separately reimbursed; follow local participation reimbursement guidance.
- Annual CPT/HCPCS updates are reflected on the Preventive Services for Commercial grid each January; policy requirement updates occur annually in June.
Cost-Sharing and Filing Risks
For in-network providers, cost-sharing rules depend on how services are billed. Preventive services billed separately may be paid without cost share while the office visit may be subject to cost share if billed separately. If the preventive service is not billed separately, assess the primary intent of the visit to determine cost-sharing applicability. Preventive services delivered out-of-network may incur member cost share.
- Colorectal cancer screening is covered without cost share beginning at age 45; see coding grid for claims processing guidelines.
- If a polyp is removed during a screening colonoscopy, that service and associated charges are paid without cost share.
- A screening colonoscopy performed after an incomplete screening colonoscopy is paid without cost share.
- A follow-up screening colonoscopy performed within six months of the initial screening colonoscopy will be considered a preventive service and processed without member cost share; contact Call Center (401-274-4848) or Provider Relations (ProviderRelations@bcbsri.org) if a claim is processed with member cost share.
Provider Action Note
Provider action note: placeholder — follow instructions in the attached code grid and the coding/documentation notes above to avoid denials or inappropriate member cost share.
Background
Preventive health services encompass primary prevention—interventions aimed at preventing the initial occurrence of disease—and secondary prevention—services intended to detect disease early or mitigate its consequences. Under the IFR, preventive services include those with an A or B USPSTF rating, immunizations recommended by ACIP/CDC, and comprehensive preventive care and screening guidelines for infants, children, adolescents, and women as supported by HRSA.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.