Preventive Health Services — Commercial Products
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
Governs coverage and claims processing for preventive health services for Commercial Products (non-Medicare Advantage) offered by Blue Cross Blue Shield - Rhode Island, including cost-sharing rules, coding guidance, and sources of recommended services.
No material clinical or coverage changes in this revision.
Coverage Criteria and Scope
General preventive services coverage
Covered when services meet recommendations from specified authoritative sources and are delivered in-network:
Coverage follows these four sources; plans may provide additional preventive services but may deny coverage for services not contained in these sources.
Cost-sharing and frequency rules
Specific cost-sharing and service frequency rules:
Out‑of‑network preventive services may be subject to cost‑sharing.
See coding grid for claims processing; contact the Call Center or Provider Relations if a follow‑up claim incorrectly applies member cost share.
If source guidelines are silent on frequency, the plan may apply reasonable medical management techniques to determine coverage limitations.
Commercial Preventive Services Coverage
Commercial preventive services are covered without member cost-sharing when they meet specified authoritative recommendations and are filed per the policy grid.
New recommendations are incorporated no later than one year after release; follow the attached Commercial Preventive Services grid for correct claim filing to ensure no member copayment, coinsurance, or deductible applies.
Plans may deny coverage for preventive services that are not included in the four authoritative sources referenced by the IFR: (1) services with an A or B rating from the U.S. Preventive Services Task Force (USPSTF); (2) immunizations recommended by the Advisory Committee on Immunization Practices (ACIP); (3) preventive care and screenings for infants, children, and adolescents as outlined in HRSA-supported guidelines; and (4) preventive care and screenings for women as outlined in HRSA-supported guidelines. The policy follows these sources when determining which services must be covered without member cost-sharing and notes that nothing in the IFR prevents a plan from providing additional preventive coverage beyond these lists.
Services that are not identified by the Patient Protection and Affordable Care Act (PPACA) as preventive health services are handled under the member's applicable benefit section in the Subscriber Agreement. Such services may be subject to member cost-sharing, including copayments, deductibles, and coinsurance, consistent with the terms of the member's contract.
Medical criteria: Not applicable.
Coding Guidance and Key Dates
| 33 | Modifier 33 — Preventive Services (apply to pathology services for preventive colonoscopy and certain injections) |
| 99401-99404 | Preventive medicine counseling and risk factor reduction services |
| 99381-99397 | Preventive medicine examination codes (include counseling and anticipatory guidance) |
| 33 | Modifier 33 (Preventive Services) |
| Z30.09 | ICD-10 code for contraceptive counseling when it is the only service performed |
Provider Billing, Filing, and Operational Requirements
PRIOR AUTHORIZATION
Prior authorization is generally not required; exceptions are noted in this policy.
Commercial Preventive Services - Claim Filing
The Commercial Preventive Services listed on the Preventive Services code grid are covered without copayment/coinsurance and deductibles. Claims must be filed as noted on the attached grid with any grid-specified diagnosis in the primary position; append modifiers as required by the grid and policy coding notes.
Cost-Sharing Rules — In-Network
Cost-sharing rules differ by provider type and circumstance. For in-network providers, whether cost-sharing applies to an office visit when a preventive service is provided depends on how services are billed and the primary intent of the visit. If the preventive service is billed separately, the plan may impose cost-sharing on the office visit but not on the preventive service. If the preventive service is not billed separately and the primary intent of the visit is preventive, cost-sharing may not be imposed. Colorectal cancer screening is covered without cost sharing beginning at age 45 (effective January 1, 2022).
- For in-network providers: If a screening colonoscopy requires polypectomy or other associated services during the same encounter, those services and associated charges are paid without member 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 (per USPSTF guidance) is considered preventive and will be covered without cost share; if a follow-up claim is processed with member cost share, contact Call Center 401-274-4848 or Provider Relations ProviderRelations@bcbsri.org to have the claim identified and reprocessed without member cost share.
Cost-Sharing Rules — Out-of-Network and Institutional Providers
For out-of-network providers, plans may apply cost-sharing requirements to preventive health services delivered by an out-of-network provider, including cost-sharing attached to the office visit and the services provided. For institutional/facility charges when preventive and non-preventive procedures occur at the same time, facility cost-sharing will not be applied if one of the procedures is considered a preventive service (e.g., facility charges for a screening colonoscopy performed with another endoscopic procedure).
- Plans may impose cost-sharing for services not identified by PPACA as preventive health services or for treatment resulting from a preventive service (e.g., medication started after a screening).
- Preventive services provided by out-of-network providers may be subject to cost-sharing.
Coding and Modifier Requirements
Append modifier 33 (Preventive Services) as specified by policy to ensure preventive classification for claims processing. In particular, append modifier 33 to pathology services for a preventive colonoscopy. Follow the Preventive Services code grid and the Additional Coding Notes for exact modifier and diagnosis requirements.
- 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 performed.
- See the Preventive Services for Commercial code grid for filing instructions and any additional required modifiers or diagnosis codes.
Background and Policy Purpose
Preventive health services encompass both primary prevention (interventions intended to avoid disease occurrence) and secondary prevention (screening and early interventions to mitigate disease consequences). Coverage under this policy is aligned with authoritative recommendations (USPSTF A/B, ACIP, and HRSA guidance) so that services shown to prevent disease or its complications are provided without member cost-sharing when delivered in-network.
Definitions and Included Recommendation Sources
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.