CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Services for Medicare Advantage Plans

Governs coverage and coding guidelines for preventive services provided to members enrolled in Blue Cross Blue Shield of Rhode Island Medicare Advantage plans, including cost-sharing waivers and claim filing instructions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Services for Medicare Advantage Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective Date02/10/2021

Next Review DateN/A

Key ActionNo prior authorization required for preventive services under this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Effective Jan 1, 2011ACA preventive coverage baseline

NonePrior authorization

G0438/G0439AWV codes referenced

G0444 restrictionsScreening billing note

6 monthsColonoscopy window

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Preventive services coverage criteria

Covered when ALL of the following are met:

Preventive services defined in the coding section of this policy are covered at no member cost share when billed according to the coding and claim-filing guidelines in this policy.

Claims must be filed according to the coding guidelines in this policy (primary diagnosis in the primary position and use of specified preventive codes) to ensure correct processing as preventive with no member cost share.

Benefits may vary by group/contract; refer to the member's Evidence of Coverage for applicable preventive health services coverage/benefits.

When preventive and non-preventive services are performed concurrently, facility cost sharing is applied only when the higher-priced procedure is non-preventive; if the higher-priced procedure is preventive, no facility cost sharing is applied.

No prior authorization is required for preventive services under this policy.

Referenced Codes and Coding Notes

Covered preventive and related codesCPT | HCPCS | mixedCovered

G0438	Annual Wellness Visit, initial
G0439	Annual Wellness Visit, subsequent
G0444	Depression screening
99385-99387	Periodic comprehensive preventive medicine evaluation (annual physical exam codes referenced)
00811	Anesthesia for lower intestinal endoscopic procedures (effective 1/1/2018)

Follow-up colonoscopy preventive window

Preventive follow-up windowA screening follow-up colonoscopy is considered a preventive service when performed within 6 months of the initial screening colonoscopy.

Action if cost share appliedIf a follow-up claim is submitted and member cost share is applied, contact the Call Center (401-274-4848) or Provider Relations (ProviderRelations@bcbsri.org) to have the claim reprocessed as preventive.

Documentation referenceFollow-up timing guidance is set forth in USPSTF-related guidance referenced in the policy.

Key Definitions

Definition of Preventive services

DefinitionPreventive services are services covered without member cost share under Medicare when recommended by the USPSTF with an A or B grade or when other statutory provisions apply.

Statutory waiversThe Affordable Care Act waives deductible and coinsurance/copayment for USPSTF A or B recommended services; other statutory provisions may waive cost sharing for specified clinical laboratory tests.

ExceptionsSome Medicare-covered preventive services do not have USPSTF A/B recommendations (e.g., digital rectal exams for prostate screening, glaucoma screening); deductible/coinsurance may still apply unless another statute waives them.

Annual Wellness Visit (AWV)

Annual Wellness Visit codesG0438 (initial) and G0439 (subsequent).

Distinction from Annual PhysicalThe Annual Physical Exam (CPT 99385-99387 or 99395-99397) is not considered a preventive service under this policy; refer to the member's Evidence of Coverage for benefit applicability.

Depression screening ruleDepression screening (G0444) will not be reimbursed when filed with the initial Annual Wellness Visit (G0438) because G0438 already includes a standardized depression screening and functional assessment; G0444 may be reimbursed if performed and documented with G0439.