CurrentBlue KCPolicy N/A

In-network Routine Preventive Care Coverage

This document summarizes Blue KC coverage for in-network routine preventive services, applicable billing guidance, and examples of covered preventive screenings, immunizations, and counseling services affecting members and their providers.

Policy Summary

PayerBlue KC

PolicyIn-network Routine Preventive Care Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill preventive services with a primary preventive diagnosis to ensure 100% in-network coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%coverage level for in-network routine preventive care

45-75colorectal screening age

15-65HIV screening age range

Annual LDCTlung screening frequency

2tobacco cessation attempts/year

Coverage Criteria for Preventive Services

General preventive coverage

In-network routine preventive care is covered at 100% when billed appropriately and subject to contract terms.

General coverage conditions: Service is in-network preventive care AND billed with a primary preventive diagnosis

Routine preventive services are subject to the terms, conditions and limitations of the member's Contract/Certificate of Coverage. Tests or treatment ordered or provided during a preventive visit that are diagnostic or for an existing condition are not preventive care and may be subject to deductibles, copays and/or coinsurance.

Listed preventive services and screening recommendations

Examples of covered preventive services and USPSTF/ACIP-recommended screenings and interventions (not an exhaustive list):

Immunizations and newborn screenings: Childhood immunizations per ACIP/CDC schedules (including routine doses and catch-up series for DTaP, polio, Hepatitis B, MMR, varicella, PCV, influenza, COVID-19, Hepatitis A, rotavirus, HPV, meningococcal, RSV, shingles, and tetanus boosters) and newborn screenings (hearing, hemoglobinopathies, phenylketonuria, congenital hypothyroidism).

Immunizations are limited to parameters recommended by ACIP/CDC; includes catch-up dosing as listed in the policy.

Cancer screenings: Breast screening (mammography), cervical screening (Pap and/or HPV per age-based recommendations), colorectal cancer screening starting at age 45 through 75, lung cancer screening with annual low-dose CT for eligible adults, skin cancer behavioral counseling and related preventive services.

Colorectal screening starting at age 45; lung screening eligibility per USPSTF criteria (Adults 50-80 with 20 pack-year history who currently smoke or quit within past 15 years).

Infectious disease screening and prevention: HIV screening (adolescents and adults ages 15 to 65 and as clinically indicated), hepatitis B and C screening per recommendations, syphilis, chlamydia and gonorrhea screening, and HIV prevention including PrEP for persons at high risk.

Includes HIV screening for pregnant women and PrEP offered to persons at high risk as referenced in USPSTF/ACIP guidance.

Maternal and pediatric preventive services: Gestational diabetes screening after 24 weeks, Rh(D) blood typing and antibody testing at first prenatal visit and repeat testing at 24–28 weeks for unsensitized Rh-negative women, preeclampsia screening with blood pressure monitoring, and aspirin prophylaxis for women at high risk for preeclampsia (low-dose aspirin after 12 weeks).

Aspirin for preeclampsia prevention recommended after 12 weeks in high-risk pregnant women per USPSTF statements.

Behavioral and counseling interventions: Tobacco use screening and cessation counseling and pharmacotherapy (includes two cessation attempts per year with up to 90-day regimens when prescribed by an in-network provider without prior authorization), alcohol screening and brief counseling, diet and physical activity counseling for weight/CVD prevention, and depression screening with systems for diagnosis and follow-up.

Tobacco cessation benefit includes two attempts per year for prescription and OTC medications for a 90-day regimen when prescribed by an in-network provider without prior authorization.

Cardiovascular prevention: Blood pressure, lipid and glucose screening; aspirin initiation for primary prevention in select adults aged 50–59 with ≥10% 10-year CVD risk who meet criteria; statin preventive medication for adults 40–75 with one or more CVD risk factors and a ≥10% 10-year risk.

Aspirin and statin recommendations include the specific age and risk thresholds cited by USPSTF in the document.

Services or procedures that are identified or ordered during a preventive care visit but are diagnostic in nature or intended to treat an existing condition are not preventive care and are not covered under the in-network preventive benefit at 100%. Such diagnostic tests or treatment services may be billed and cost-shared separately and can be subject to the member’s deductible, copayments, and/or coinsurance. Providers should bill preventive services with a primary preventive diagnosis when appropriate to ensure the in-network preventive coverage applies.

Services furnished by an out-of-network provider are subject to the member’s out-of-network deductible and coinsurance. An important exception: childhood immunizations are paid at 100% even when administered by an out-of-network provider. Providers and billing staff should confirm network status and apply the appropriate billing rules; this summary is informational and subject to plan terms and change.

Not applicable statements are not provided in this policy. If a condition is diagnosed or treatment is provided during a preventive visit (or if the member presents with symptoms), those services are categorized and billed separately from the preventive benefit. In practice, that means providers must distinguish preventive services from diagnostic or therapeutic services on the claim: preventive services billed with the appropriate primary preventive diagnosis are eligible for in-network coverage at 100%, whereas diagnostic/treatment services identified during the visit may be subject to standard cost sharing.

Coding and Screening Eligibility

No specific CPT/HCPCS/ICD-10 codes listedmixed

No codes listed

inv-07: Aspirin prevention age/risk threshold — initiating low-dose aspirin for primary prevention

Age and risk thresholdAdults aged 50-59 with a 10% or greater 10-year cardiovascular (CVD) risk for initiating low‑dose aspirin for primary prevention

Aspirin regimen contextInitiating low‑dose aspirin use for primary prevention of cardiovascular disease and colorectal cancer

Bleeding and life-expectancy considerationsApplicable when individuals are not at increased risk for bleeding and have a life expectancy of at least 10 years

Duration expectationWillingness to take low‑dose aspirin daily for at least 10 years

Source guidance linkageRecommendation derived from USPSTF preventive medication guidance referenced in the policy

inv-08: Lung cancer screening eligibility

Age rangeAdults aged 50 to 80 years

Smoking history20 pack‑year smoking history

Current or former smokersCurrent smokers or those who have quit within the past 15 years

Screening modality and frequencyAnnual screening with low‑dose computed tomography (LDCT)

Discontinuation criteriaStop screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or ability/willingness for curative lung surgery

Provider Actions, Billing & Prior Authorization

Prior Authorization

Tobacco Cessation — No Prior Authorization for 2 Attempts/Year

Two tobacco cessation attempts per member per year are covered when prescribed by an in‑network provider for up to a 90‑day regimen without prior authorization. This applies to both prescription and over‑the‑counter medications when billed as part of recommended preventive services.

Applies to adults and pregnant women as noted in USPSTF recommendations.
Coverage: two attempts per year, each up to a 90‑day regimen, without prior authorization when prescribed by an in‑network provider.

Billing Rule

Billing Diagnosis & Network Rules

When providing preventive services, bill with a primary preventive diagnosis to ensure 100% coverage. If tests or treatment for a non‑preventive condition are performed during the visit, those items may be subject to member cost‑sharing.

If the visit includes diagnostic testing or treatment for an existing condition, bill those services with the appropriate non‑preventive diagnosis — they may be subject to deductible/copay/coinsurance.
Childhood immunizations received from out‑of‑network providers are paid at 100%; other out‑of‑network preventive services remain subject to out‑of‑network deductible and coinsurance.

Documentation Required

Provider Actions — Documentation & Coding

Providers should document preventive intent and the primary preventive diagnosis on the claim. Failure to bill with a primary preventive diagnosis may result in services not being paid at the 100% preventive benefit and could lead to member cost‑sharing.

Include documentation that supports preventive care (e.g., screening purpose, counseling, immunization) in the medical record and on the claim.
When ordering additional tests during a preventive visit, clearly distinguish preventive services from diagnostic/treatment services in billing and documentation.

Background and Evidence Sources

This policy references national guidance that informs covered preventive services and screening intervals, including recommendations from the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP)/CDC, and the Health Resources and Services Administration (HRSA). These sources guide examples of covered immunizations, screenings, counseling, and preventive interventions; providers should follow those evidence-based recommendations when delivering preventive care and consult plan-specific documents for coverage and billing details.

Definitions

inv-14: Routine preventive care — definition and billing guidance

DefinitionIn‑network routine preventive care and the related office visit intended for prevention and screening that, when billed with a primary preventive diagnosis, are covered at 100% subject to contract terms

Billing requirementMost preventive services must be billed with a primary diagnosis of 'preventive' to be covered at 100%

Contract limitationRoutine preventive services are subject to the terms, conditions and limitations of the member's Contract/Certificate of Coverage; not all plans cover all preventive services at 100%

Non‑preventive services during visitTests or treatment for existing conditions or diagnostic services ordered during a preventive visit are not preventive care and may be subject to deductibles, copays, and/or coinsurance