Preventive Health Services Coverage (Commercial)
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Defines coverage, coding, and cost-sharing rules for preventive health services for Blue Cross Blue Shield - Rhode Island Commercial products, including which guideline sources determine covered services and billing guidance for claims processing.
No material clinical or coverage changes in this revision.
Coverage Criteria for Preventive Services
Covered Preventive Services (Commercial, In-Network)
Covered when services meet recommendations from one of the following authoritative sources and are delivered in‑network:
Coverage follows these sources; newly recommended preventive services adopted no later than one year after recommendation release.
Preventive Services for Commercial Members
Covered when meeting the conditions below:
Services listed on the Commercial Preventive Services grid are covered without copayment, coinsurance, or deductible when billed per the grid. Services not identified by PPACA may be covered under the member’s Subscriber Agreement and may incur cost share.
Guideline Alignment Requirement
Coverage must follow recommendations from one of the following authoritative sources:
New preventive recommendations will be adopted no later than one year after the recommendation release date.
Services described as preventive in this policy are covered without cost-sharing when they align with the referenced authoritative sources and are delivered in‑network. The policy relies on the IFR reference sources: USPSTF recommendations graded A or B, ACIP immunization schedules, HRSA pediatric/adolescent (Bright Futures) guidance, and HRSA women’s preventive services. Nothing in the IFR prevents a plan from choosing to cover additional services; however, services not contained in the four referenced sources may be denied as preventive services or subject to plan cost‑sharing when provided outside these references. (See examples in the commercial products guidance regarding treatment resulting from a preventive screening and facility charges when preventive and nonpreventive services are performed together.)
Some plans are grandfathered and are exempt from the preventive services requirements described in this policy. Coverage obligations and cost‑sharing exemptions that apply to non‑grandfathered plans do not apply to grandfathered plans; providers must verify member benefits and subscriber agreements for applicability.
Not applicable.
If services are determined to be not medically necessary or are otherwise non‑covered benefits under the member’s plan, those services may be denied and billed according to the member’s subscriber agreement. Providers may not charge the member for services determined to be non‑covered or not medically necessary unless the member was informed in advance and provided written agreement to assume payment.
Coding, Age Thresholds, and Incorporation Timing
| 33 | Modifier 33 — Preventive Services (apply to pathology for preventive colonoscopy and injectable contraceptive) |
| 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) — appended to specified services |
| Z30.09 | ICD-10 code for contraceptive counseling when it is the only service performed |
Provider Actions, Claims Filing, and Billing Rules
Prior authorization generally not required (exceptions noted)
Prior authorization is generally not required for preventive services; exceptions are noted elsewhere in this policy. Preventive services listed on the Commercial Preventive Services grid are covered without copayment/coinsurance/deductible when claims are filed according to the grid instructions.
Preventive services on commercial grid covered without patient cost share
Preventive services listed on the Commercial Preventive Services grid are covered without copayment, coinsurance, or deductible when billed per the grid; file claims as noted on the grid with the listed diagnosis in the primary position.
- Services on the commercial grid are covered without patient cost-sharing when billed per the grid.
Billing interactions between preventive services and office visits
Where a preventive service is billed separately from an office visit, the plan may impose cost-sharing on the office visit but not on the preventive service; where not billed separately, cost-sharing is determined by the primary intent of the visit.
- If preventive service billed separately: preventive service processed without cost share; office visit may incur cost share.
- If not billed separately: no cost share if primary intent was preventive; otherwise cost-sharing may apply.
Cost-sharing for out-of-network and facility charges
Out-of-network providers: plans may apply cost-sharing to preventive services delivered by out-of-network providers, including cost-sharing attached to the office visit and the actual services provided.
- Facility charges: when preventive and nonpreventive services are performed concurrently, facility cost-sharing will not be applied if one procedure is a preventive service.
- Plans may still impose cost-sharing for preventive services delivered by out-of-network providers.
Use modifier 33 for specified preventive services (e.g., colonoscopy pathology)
Append modifier 33 (Preventive Services) to applicable preventive services per coding guidance — specifically to pathology services for a preventive colonoscopy and to injections filed with a contraceptive; use modifier 33 where the grid or coding notes require it.
- Append modifier 33 to pathology for preventive colonoscopy.
- Append modifier 33 to an injection filed with a contraceptive and to counseling when contraceptive counseling is the only service.
File claims per Preventive Services grid with primary diagnosis and required modifiers
File claims for preventive services as directed on the Commercial Preventive Services grid with the diagnosis listed in the primary position; when contraceptive counseling is the only service, append ICD-10 code Z30.09 and modifier 33 as instructed.
- Claims must follow the attached grid and list the grid-specified diagnosis in primary position.
- When contraceptive counseling is the only service, use ICD-10 Z30.09 and append modifier 33.
Denial risk and member billing restrictions for non-covered or not medically necessary services
Services determined to be not medically necessary or otherwise non-covered may be denied; if a service is denied as not medically necessary (or is a non-covered benefit), the provider may not charge the member unless the member was informed and agreed in writing in advance.
- Denials for not medically necessary or non-covered services carry member billing restrictions — written member agreement required before billing the member.
- Benefits and eligibility are governed by the member's subscriber agreement or employer agreement; provider participation agreements may impose additional obligations.
Risk of denial and member billing for out-of-network or non-referenced preventive services
Non-covered preventive services, services not contained in the referenced guideline sources, or services delivered by out-of-network providers may be subject to plan-imposed cost-sharing or denial; providers should follow the grid and participation agreements to avoid member balance billing.
- Services outside the four referenced sources may be denied as preventive services or subject to cost-sharing.
- Do not bill members for denied or non-covered services unless the member provided prior written agreement.
Background on Preventive Services
Preventive health services include both primary prevention (interventions to avoid the occurrence of disease) and secondary prevention (screening and early detection to mitigate consequences of disease). This policy aligns coverage with recognized authoritative recommendations: USPSTF A/B recommendations, ACIP immunization guidance, HRSA pediatric/adolescent (Bright Futures) guidance, and HRSA women’s preventive services. Services meeting those sources and billed per the preventive services grid are covered in‑network without copayment, coinsurance, or deductible; newly recommended preventive services are adopted by the plan within one year of recommendation release.
Definitions and Scope
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