Preventive Health Services (Commercial Products) Coverage and Coding Guidelines
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Defines coverage and coding guidelines for preventive health services for Commercial Products, specifying services covered without cost-share when delivered in-network and rules for claims processing.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered Preventive Services
Covered when the service meets one of the referenced recommendations and is delivered in-network under the member's preventive benefit:
Coverage follows the frequency/method in the referenced guideline when specified; otherwise the plan may apply reasonable medical management techniques.
Preventive services delivered by out-of-network providers may be subject to cost-sharing.
Colorectal Cancer Screening Specifics
Colorectal screening coverage rules:
Effective January 1, 2022; see coding grid for claims processing.
Claims should be filed per the coding grid; append modifier 33 where applicable.
Follow claims filing guidance to ensure processing as preventive.
If member cost share is applied in error, contact Call Center or Provider Relations to have the claim reprocessed as preventive.
Commercial Preventive Services Coverage Criteria
Covered when ALL of the following are met
Coverage must follow these source recommendations.
Applies to all sources cited in the policy.
Failure to file as specified may affect processing and lead to denial; updates to coding are reflected annually and on the attached grid.
Coverage under this policy is limited to services identified as preventive by the federal references cited in the IFR. Covered preventive services are those recommended by at least one of the following sources: USPSTF with an A or B rating, ACIP (CDC) immunization recommendations, HRSA-supported comprehensive guidelines for pediatric preventive care, and HRSA-supported comprehensive guidelines for women’s preventive services. The IFR and its preamble list the preventive services that must be covered without cost-sharing when delivered by an in‑network provider. Nothing in the IFR prevents a plan from covering additional preventive services, but plans may deny coverage for services not contained in these four referenced sources.
Services that are not identified by the PPACA as preventive health services (i.e., not listed in the federal preventive sources) are not covered under this preventive policy. Such services are instead processed under the member’s applicable benefit section of the Subscriber Agreement and may be subject to cost-sharing (copayments, deductibles, coinsurance) according to that benefit.
Some group or individual plans retain a grandfathered status under federal law. Grandfathered plans are exempt from the preventive services requirements described in this policy and therefore are not required to provide the no-cost preventive protections set forth for non‑grandfathered plans.
Because grandfathered plans are not subject to the PPACA preventive services mandate, they may not provide the preventive coverage protections described elsewhere in this document. Providers and members should verify benefit design and applicable coverage rules under the member’s specific plan to determine whether preventive services receive the protections described in this policy.
Coding and Billing Guidance
| 33 | Modifier 33 — Preventive Services (append to pathology services for a preventive colonoscopy and to injection filed with a contraceptive) |
| 99381-99397 | Preventive medicine evaluation and management codes (include counseling; should not be filed same date as 99401-99404) |
| 99401-99404 | Preventive medicine counseling and risk factor reduction services (separate face-to-face encounters) |
| 33 | Modifier 33 (Preventive Services) — append to specified preventive services (e.g., pathology for preventive colonoscopy, counseling services) |
| Z30.09 | ICD-10 Code Z30.09 — use when contraceptive counseling is the ONLY service performed during the encounter |
Provider Actions & Billing Requirements
Prior Authorization
Prior authorization is generally not required; exceptions are noted in this policy. Providers should verify prior authorization requirements for any service not explicitly listed as exempt.
- Prior authorization generally not required; check policy for exceptions
Coverage When Billed Per Grid
The Commercial Preventive Services listed on the code grid are covered without copayment/coinsurance and deductibles when claims are filed per the attached grid. Claims must be filed with the diagnosis listed on the grid in the primary position. Follow the grid's filing instructions to ensure preventive benefit application.
- Claims for commercial preventive services must be filed per the code grid
- Place the grid-specified diagnosis code in primary position on the claim
Out-of-Network Cost-Sharing Risk
For preventive services delivered by out-of-network providers, plans may apply cost-sharing. In-network billing conventions determine member cost-share applicability; confirm network status and billing method before filing.
- Out-of-network preventive services may be subject to cost-sharing
- In-network cost-sharing depends on whether the preventive service is billed separately or as part of the office visit
Claims Filing and Modifier Use
Providers must follow specific claims filing and modifier conventions to ensure preventive services are processed without member cost share where applicable.
- Append modifier 33 to pathology services for a preventive colonoscopy
- Append modifier 33 to injections filed with a contraceptive and to counseling services when appropriate
- When contraceptive counseling is the ONLY service performed, append ICD-10 code Z30.09 in primary position and modifier 33 as applicable
- Preventive Evaluation & Management (99381-99397) should not be filed on the same date as preventive counseling codes (99401-99404)
Required Claim Modifiers and Diagnosis Coding
Append modifier 33 and use appropriate diagnosis coding in primary position per the code grid. Ensure annual CPT/HCPCS updates are reflected per the Preventive Services for Commercial grid.
- Append modifier 33 (Preventive Services) where specified (pathology for preventive colonoscopy, contraceptive injections, preventive counseling)
- Use the grid-specified diagnosis in primary position on the claim
- Policy updates are made annually; ensure claims reflect current CPT/HCPCS coding as shown on the January grid
Provider Action: Screening Colonoscopy Billing
Provider action: If a screening colonoscopy requires polypectomy or other treatment during the screening, those associated services and charges are paid without cost share. If a follow-up screening colonoscopy is performed within six months of the initial screening, it will be considered preventive and processed without member cost share; contact the Call Center or Provider Relations if a processed claim applied member cost share.
- Polyp removal during screening colonoscopy is paid without member cost share
- Follow-up screening colonoscopy within six months is considered preventive and should have no member cost share
- If a claim incorrectly applied member cost share, contact Call Center 401-274-4848 or ProviderRelations@bcbsri.org to request reprocessing
Definitions
Background
Preventive health services encompass both primary prevention (interventions intended to avoid the occurrence of disease) and secondary prevention (screening and early interventions intended to detect disease early and mitigate its consequences). Coverage under this policy aligns with the IFR definition and follows federal guidance: services that meet USPSTF A/B recommendations, ACIP immunization guidance, and HRSA‑supported pediatric and women’s preventive care guidelines are the basis for no‑cost in‑network coverage. Where those sources specify frequency, method, or follow‑up, the plan follows those recommendations; if they do not, the plan may apply reasonable medical management consistent with the guidance.
Revision History
Policy baseline effective date: coverage applies to plan years beginning on or after September 23, 2010.
Policy requirements are updated annually in June; CPT and HCPCS annual coding updates are reflected on the Preventive Services for Commercial grid for January.
New preventive service recommendations are implemented no later than one year after the release date of the recommendation.
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