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.

ModifiedEmblemHealthPolicy N/A

Preventive Services & Screening — Coverage Criteria

Customize your policy alerts

Sign up for all EmblemHealth policy alerts

Know when EmblemHealth releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines EmblemHealth coverage, cost-sharing, and coding for preventive services and screenings (commercial and Medicaid), including specific services, frequencies, and device benefits; applies to network providers and members of non-grandfathered and grandfathered plans as noted.

Policy Summary

PayerEmblemHealth

PolicyPreventive Services & Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeMultiple coding and frequency updates (additions/clarifications)

Effective DateVaries by item

Next Review DateN/A

Key ActionSubmit preventive services with the appropriate preventive ICD-10 diagnosis codes and procedure CPT/HCPCS codes so they are processed under the preventive benefit.

SourceLink

POLICY UPDATE CHANGES

Chlamydia and Gonorrhea combined testing effective 1/1/2026.

ICD-10 codes Z86.0100, Z86.0101, Z86.0102, Z86.0109 added effective 10/1/2024 for Colon Cancer Screening.

ICD-10 code Z86.010 deleted effective 10/1/2024.

ICD-10 code Z01.818 removed effective 6/1/2024 for screening colonoscopy pre-procedure consultations.

New procedure codes: Cologuard Plus (0464U) effective 9/01/2025 and Shield (0537U) effective 1/1/2026 for colorectal cancer screening.

Diabetes Screening: Gestational frequency revised to 3x/year effective 1/01/2024.

Added new HCPCS code A4288 to Breast Pump Supplies, effective 10/1/2025.

Included COVID vaccine code 91323, effective 8/27/2025.

Added Influenza vaccine updates for 2025-2026 and added multiple vaccine and screening CPT/HCPCS codes (e.g., 0455U, 0537U).

Clarified that providers must adhere to CDC/ACIP guidelines for certain RSV and influenza age/frequency instructions and that EmblemHealth Medicaid reimburses only codes found on the Medicaid fee schedule.

1x/year

General adult preventive visit frequency

1x/pregnancyBreast pump benefit

200 units/30 daysBreast pump supplies

45-75 yrsColon cancer screening interval

Once/5 yrsColonoscopy frequency

UnlimitedHIV screening frequency

Coverage Criteria for Preventive Services & Screening

General preventive coverage criteria

Covered when ALL of the following are met

Network & Plan Status: Service provided by a Network provider for non-grandfathered plans to be covered without member cost sharing

Member Cost-Sharing: non-grandfathered plans covered at 100% when provided by a Network provider (see member cost-sharing).

Preventive vs Diagnostic: Service must be appropriately reported as preventive (asymptomatic individual, within recommended screening interval with prior normal findings, or following normal diagnostic results) to be considered under the preventive benefit; services performed for diagnostic indications are billed to the non-preventive benefit

From Preventive vs. Diagnostic Services section

Guideline Basis: Service aligns with USPSTF A/B recommendations, ACIP immunization recommendations, or HRSA/AAP Bright Futures guidelines to qualify under the PPACA preventive benefit

Introduction: PPACA required services (USPSTF A/B, ACIP, HRSA/AAP).

Breast pump and supplies

Covered when ALL of the following are met

Breast pump device: Personal-use electric breast pump (HCPCS E0603) or hospital-grade pump (E0602) covered when provided by network provider; benefit limited to one pump per pregnancy/birthOne pump per pregnancy

Breast Pumps frequency: 1x/pregnancy (see Breast Pumps section).

Breast pump supplies (HCPCS A4281–A4288 and A4287 as listed) are covered when billed with the appropriate ICD-10 (e.g., Z39.1) and subject to frequency/quantity rules200 units per 30 days (supplies)

Preventive Benefit Instructions: supplies frequency example 200 units/30 days; new supply codes and effective dates noted in revision history.

Imaging and cancer screening

Covered when ALL of the following are met

AAA screening: Abdominal aortic aneurysm screening (CPT 76706) covered 1x per lifetime for ages 65-75 when billed with appropriate ICD-10 diagnosis codes1x/lifetime, ages 65-75

See Specific Screenings (AAA) for ICD-10 mappings.

Colon cancer screening: Colorectal cancer screening (colonoscopy, CT colonography, pathology, anesthesia and ancillary services, and stool-based molecular tests) covered when billed with listed procedure and ICD-10 codesOnce every 5 years for colonoscopy/CT colonography/pathology; stool-based tests (including Cologuard) once every 3 years per instructions

Colorectal screening ages: 45-75 (colonoscopy/CT/pathology); stool-based ages: 45-85 for FOBT/Cologuard. New test codes and ICD-10 additions noted.

Mammography/tomosynthesis: Screening mammography and breast tomosynthesis codes (tomosynthesis when used as supplemental imaging) covered per listed CPT codes and frequencies; tomosynthesis may be used in addition to mammography and is covered per the provided frequency guidance

Obesity screening and behavioral interventions

Covered when ALL of the following are met

Obesity screening - children: Screening for obesity in children and adolescents (>=6 years) is covered with referral or provision of comprehensive intensive behavioral interventions; applicable preventive counseling and medical nutrition therapy codes are coveredFrequency: 4x/year (children/adolescents)

ICD-10 obesity codes listed; preventive benefit instructions specify 4x/year frequency.

Obesity screening - adults: Adults with BMI >= 30.0 are eligible for intensive multicomponent behavioral interventions; preventive counseling codes and medical nutrition therapy codes are coveredFrequency: up to 12x/year (adults); BMI >= 30.0

USPSTF recommendations and BMI thresholds referenced; preventive benefit instructions list frequency 12x/year.

Chlamydia Screening

Covered when meeting listed age/frequency and using specified codes

Chlamydia Screening: Screening for chlamydia is covered when billed with the listed ICD-10 screening diagnosis codes (e.g., Z00.00, Z00.01, Z11.3, Z11.4, Z11.8, Z11.9, Z20.2, Z20.6, Z72.51, Z72.52, Z75.53) and the listed procedure/test CPT codesFrequency: Screening 1x/year; Pregnancy: 3x/year

Document notes combined chlamydia/gonorrhea testing effective 1/1/2026 and lists applicable procedure codes (86631/86632, 87490/87491, 87492, 87801, 87810, 0455U etc.).

Colon and Colorectal Cancer Screening

Covered colorectal/colon cancer screening options with code- and age-based rules

Colon/Colorectal Screening Options: Colonoscopy (selected CPT examples listed), CT colonography (74263), pathology (88305), anesthesia/ancillary services (00811/00812), stool occult blood tests (82270/82274), and molecular stool tests (e.g., Cologuard 81528 and new codes 0464U/0537U as listed) are covered when billed with the appropriate ICD-10 screening diagnosis codesFrequencies: Colonoscopy/CT colonography/pathology once every 5 years for ages 45-75; stool-based tests (including Cologuard) once every 3 years for ages 45-85 as specified

ICD-10 codes added effective dates and new molecular test codes are provided in the document; follow frequency and age limits per line items.

Diabetes Screening

Diabetes screening guidance

Diabetes Screening (Adults and Children): Screening for diabetes is covered using listed glucose/HbA1c procedure codes and appropriate ICD-10 diagnosis codes for adults and children; gestational diabetes screening is covered with pregnancy-specific ICD-10 codesFrequency: Adults and children 1x/year; Gestational: updated to 3x/year effective 1/01/2024 (previously 2x/year)

See Diabetes Screening entries for procedure codes (82947, 82948, 82950, 82951, 82952, 83036) and the pregnancy appendix for gestational ICD-10 codes.

Gonorrhea Screening

Gonorrhea screening coverage

Gonorrhea Screening: Screening for gonorrhea is covered when billed with the listed procedure codes (87590, 87591, 87592, 87801, 87850 and combined testing 0455U effective 1/1/2026) and appropriate ICD-10 screening diagnosis codesFrequency: Screening 4x/year; Pregnancy: 3x/year; Ages: All

Document indicates combined chlamydia/gonorrhea testing effective 1/1/2026 and provides ICD-10 mappings for adult/child/other screening encounters.

HIV Screening

HIV and other routine screenings

HIV Screening: HIV screening for adolescents and adults is covered when billed with the listed HIV screening procedure and appropriate ICD-10 screening diagnosis codesFrequency: Unlimited; Ages: All

HIV screening frequency is unlimited per Preventive Benefit Instructions; see HIV and HPV Screening Codes group for procedure codes (e.g., 86689, 87389).

Covered preventive services

Covered preventive services when billed with listed CPT/HCPCS and appropriate ICD-10 codes and within specified age/frequency limits

Newborn metabolic screens (PKU, hypothyroidism, sickle cell): Newborn metabolic screening tests are covered when billed with the listed procedure codes and appropriate ICD-10 mappings for ages 0-3 monthsAges 0-3 months; frequency 1x/year

See Newborn Screening entries (PKU, hypothyroidism, sickle cell) for CPT/HCPCS examples and frequency.

Osteoporosis screening (DXA/ultrasound CPT codes 76977, 77080, 77081) is covered per the effective-date-specific age and frequency rules; individuals with fragility fracture history have separate age/frequency rulesUntil 12/31/2025: every 23 months for ages 60+; Effective 1/1/2026: every 24 months for ages 65+ (or ages 40-65 with fragility fracture ICD-10 Z87.310 AND Z13.820)

See Osteoporosis Screening entries for effective date change and ICD-10 criteria.

Pap smear: Cervical cytology (Pap smear) is covered when billed with listed CPT cytology codes and appropriate ICD-10 screening diagnosis codes

Vaccine coverage criteria

Covered when vaccine administration aligns with listed procedure code and the member is within the indicated age/benefit limits and providers adhere to CDC/ACIP guidance where specified.

General vaccine coverage: Administration of the listed vaccine CPT/HCPCS product and administration codes is covered when the member is within the age/benefit limits specified for each vaccine and provision follows FDA/CDC/ACIP guidanceMember within age/benefit limits specified per vaccine code (see individual vaccine entries)

Examples: Hepatitis B codes 90744–90748 with pediatric/adult age bands; HPV 90649–90651 coverage instructions and age limits; Influenza codes with age-specific recommendations; RSV vaccines require adherence to CDC/ACIP guidelines and have age-specific indications.

Examinations, screenings, testing, or vaccines are not covered under the preventive benefit when performed solely for administrative purposes such as employment, school, travel, licensing, or similar requirements; when related to judicial or administrative proceedings; when conducted for medical research; or when required to obtain or maintain any license. These services may be covered under other portions of the member’s medical benefit, but are excluded from the preventive care benefit.

Providers should also be aware that services excluded from the preventive benefit remain subject to standard coding and coverage rules and could be reimbursable under non‑preventive benefits when medically indicated.

Vaccines are covered only when they meet FDA labeling requirements and have explicit routine‑use recommendations published by the Advisory Committee on Immunization Practices (ACIP) in the CDC Morbidity and Mortality Weekly Report (MMWR). A vaccine that does not meet both conditions is not covered under this preventive policy.

ICD‑10 code Z01.818 has been removed for screening colonoscopy pre‑procedure consultations effective 6/1/2024 and is no longer valid for submission under the preventive benefit for those consultations. Providers must use the currently listed diagnosis codes for preventive colonoscopy encounters.

There are no separate exclusions stated for routine immunizations beyond the general exclusions; however, immunizations must be provided in accordance with FDA licensure and CDC/ACIP age and frequency guidelines. Non‑adherence to those guidelines may affect benefit applicability or billing.

For EmblemHealth Medicaid plans, reimbursement is limited to codes that appear on the applicable Medicaid fee schedule. Codes not listed on the Medicaid fee schedule(s) will be denied for Medicaid members.

Services that are investigational, experimental, unproven, or not medically necessary are excluded from coverage under this preventive policy. Such services should not be billed under the preventive benefit and may be denied.

This section summarizes general coverage expectations: preventive services are covered only when billed with the appropriate diagnosis and procedure codes, provided by network providers as required for the preventive benefit, and delivered in accordance with referenced clinical guidelines and program instructions.

Providers must follow the policy’s coverage criteria, coding guidance, and preventive versus diagnostic reporting rules when submitting claims; diagnostic indications should be billed to the appropriate non‑preventive benefit.

Within the parts of the document cited in the revision history and administrative notes, there are no explicit additional statements labeling specific services as 'not medically necessary.' Routine determinations of medical necessity remain subject to standard clinical review and plan terms.

CPT / HCPCS / ICD-10 Codes and Frequency Guidance

General Preventive Screening and Counseling CPT CodesCPTCovered

99383	Preventive screening examination and counseling service
99384	Preventive screening examination and counseling service
99385	Preventive screening examination and counseling service
99386	Preventive screening examination and counseling service
99387	Preventive screening examination and counseling service
99393	Preventive screening examination and counseling service (periodic)
99394	Preventive screening examination and counseling service (periodic)
99395	Preventive screening examination and counseling service (periodic)
99396	Preventive screening examination and counseling service (periodic)
99397	Preventive screening examination and counseling service (periodic)

Breast pumpsHCPCSCovered

E0602	Breast pump, hospital-grade
E0603	Personal-use electric breast pump

Breast pump suppliesHCPCSCovered

A4281	Breast pump supplies
A4282	Breast pump supplies
A4283	Breast pump supplies
A4284	Breast pump supplies
A4285	Breast pump supplies
A4286	Breast pump supplies
A4288	Breast pump supplies (new code effective 10/1/2025)
A4287	Breast pump supplies (new code effective 1/1/2024)

AAA ScreeningCPTCovered

76706

Abdominal aortic aneurysm screening (ultrasound)

Breast imaging and tomosynthesisCPTCovered

77061	Breast tomosynthesis
77062	Breast tomosynthesis
77063	Breast tomosynthesis (use in addition to mammography codes)
77065	Mammography screening
77066	Mammography diagnostic
77067	Mammography diagnostic
76641	Breast supplemental imaging
76642	Breast supplemental imaging
77048	Mammography (other)

Colon cancer screening and ancillary codesCPTCovered

00811	Anesthesia for lower intestinal endoscopic procedures
00812	Anesthesia for lower intestinal endoscopic procedures
88305	Pathology examination (ancillary services)
74263	CT colonography
44388	Colon resection, endoscopic (example from list)
45378	Colonoscopy with biopsy
45380	Colonoscopy therapeutic

Obesity and weight counselingCPTCovered

99401	Preventive medicine counseling, individual
99402	Preventive medicine counseling, individual
99403	Preventive medicine counseling, individual
99404	Preventive medicine counseling, individual
97802	Medical nutrition therapy, initial assessment and intervention
97803	Medical nutrition therapy, re-assessment and intervention
97804	Medical nutrition therapy, group

Chlamydia (and combined chlamydia/gonorrhea) testingCPTCovered

86631	Chlamydia test
86632	Chlamydia test
87490	Chlamydia NAAT
87491	Chlamydia NAAT
87492	Gonorrhea NAAT
87801	Chlamydia/Gonorrhea antigen test
87810	Chlamydia/Gonorrhea antigen test
0455U	Molecular test code

Chlamydia Screening ICD-10 CodesICD-10

Z00.00	General adult exam
Z00.01	General adult exam with abnormal findings
Z11.3	Encounter for screening for infections with a predominantly sexual mode of transmission
Z11.4	Encounter for screening for other infectious and parasitic diseases
Z11.8	Encounter for screening for other specific infectious and parasitic diseases
Z11.9	Encounter for screening, unspecified
Z20.2	Contact with and (suspected) exposure to infections carried by sexual contact
Z20.6	Contact with and (suspected) exposure to HIV
Z72.51	High-risk heterosexual behavior
Z72.52	High-risk homosexual behavior

1–10 of 11

1/2

Colon Cancer Screening Procedure Codes (selected group from list)CPTCovered

44388	Colon resection, endoscopic (example from list)
45330	Colonoscopy, diagnostic, including collection of specimen(s) by brushing or washing, when performed (example)
74263	CT colonography
88305	Pathology services, surgical pathology, gross and microscopic examination

Gonorrhea/Chlamydia Screening Procedure CodesmixedCovered

87590	Chlamydia trachomatis detection
87591	Chlamydia trachomatis detection, other
87592	Neisseria gonorrhoeae detection
87801	Chlamydia/Gonorrhea NAAT (example)
87850	Chlamydia/Gonorrhea amplification
0455U	Chlamydia and Gonorrhea combined testing (effective 1/1/2026)

Molecular Stool-based Colorectal Screening CodesmixedCovered

81528	Cologuard colorectal cancer screening test
0464U	Cologuard Plus™ Lab Test (effective 9/01/2025)
0537U	Shield™ (Guardant Health) colorectal screening (effective 1/1/2026)

HIV and HPV Screening CodesCPTCovered

86689	HIV antigen/antibody screening
87389	HIV antibody
87624	HPV DNA testing (example)

Behavioral and Diabetes Screening CodesmixedCovered

96127	Brief emotional/behavioral assessment (screening)
82947	Glucose; quantitative, blood (example)

Maternity & Newborn screening CPT/HCPCSmixedCovered

59400, 59510, 59610, 59618	Maternity, Global procedure codes
99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215	Maternity initial visit E/M procedure codes
84437, 84443	Newborn screening: Hypothyroidism
84030, S3620	Newborn screening: PKU

Newborn & Osteoporosis screeningCPTCovered

83020, 83021, 83051	Newborn screening: Sickle Cell Disease
76977, 77080, 77081	Osteoporosis screening (DXA/ultrasound)

Pap SmearCPTCovered

88141

Pap smear cytology CPT codes (panel includes 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175)

Pregnancy screening panels & testsCPTCovered

81007, 87086, 87088	Pregnancy bacteriuria screening
85025, 85027	Pregnancy blood count
80081	Pregnancy obstetric panel (includes HIV testing)
87340, 87341	Pregnancy Hepatitis B screening
86901	Pregnancy Rh (D) typing
80055	Pregnancy screening panel

PrEP monitoring, HIV and STI testing codesmixedCovered

G0012, J0739, G0011, G0013	PrEP administration and counseling codes (cabotegravir injection J0739; counseling codes listed)
82565, 82575	Creatinine testing (PrEP monitoring) (3x per year)
81025, 84702, 84703	Pregnancy screening tests (unlimited for individuals of childbearing potential)
86689, 86701, 86702, 86703, 87389, 87390, 87391, 87806	HIV screening (unlimited)
86592, 86593, 86631, 86632, 86780, 87110, 87140, 87164, 87166, 87285, 87270, 87320, 87490, 87491, 87492, 87590, 87591, 87592, 87800, 87801, 87810, 87850, 0455U	STI screening panel (many codes; 4x/year), 0455U effective 1/1/2026
81002, 81003, 81005	Urinalysis (1x/year)

Cessation & sterilization codesmixedCovered

99401, 99402, 99403, 99406, 99407	Smoking cessation counseling procedure codes
58340, 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264	Sterilization procedure codes
00851, 88302, 88305	Sterilization ancillary services
74740, 76830, 76857	Sterilization follow-up services (2x/lifetime)

TB, specimen collection, vision screeningCPTCovered

86480, 86481, 86580	TB testing codes
36415, 36416	Venipuncture & capillary blood specimen collection
99173, 99174, 99177	Vision screening (visual acuity and instrument-based)

Immunizations and vaccine administration codesCPT/HCPCSCovered

90460, 90461, 90471, 90472, 90473, 90474, 90480	Immunization administration (adult/pediatric)
91304, 91318, 91319, 91320, 91321, 91322, 91323	COVID-19 vaccine product codes (various manufacturers)
90587	Dengue vaccine (Dengvaxia®)
90702, 90700, 90723, 90696, 90697, 90698, 90714, 90715	Various DTaP/DT/Tdap and combination vaccine CPT codes
90632, 90633, 90634, 90636	Hepatitis A vaccine codes
90739, 90740, 90743, 90744, 90746, 90747, 90748	Hepatitis B vaccine codes
90647, 90648	HIB vaccine codes
90649, 90650, 90651	HPV vaccine codes (Gardasil/Gardasil9 and others)

Hepatitis BCPTCovered

90744	Hepatitis B
90746	Hepatitis B
90747	Hepatitis B
90748	Hepatitis B

HIB and HPV vaccinesCPTCovered

90647	HIB (PedvaxHIB®)
90648	HIB (ActHIB®)
90649	HPV (Gardasil®)
90650	HPV
90651	HPV (Gardasil9®)

Influenza vaccinesCPT | HCPCSCovered

90653	Influenza vaccine (Fluad aIIV3)
90656	Influenza vaccine (Afluria, Fluarix, FluLaval, Fluzone)
90657	Influenza vaccine (Afluria/Fluzone 5ml MDV)
90658	Influenza vaccine (Afluria/Fluzone 5ml MDV)
90660	Influenza vaccine (Flumist® LAIV3)
90661	Influenza vaccine (Flucelvax ccIIV3)
90662	Influenza vaccine (Fluzone High-Dose HD-IIV3)
90673	Influenza vaccine (Flublok RIV3)
Q2039	Influenza virus vaccine, not otherwise specified

MMR, Meningococcal, PneumococcalCPTCovered

90707	MMR (MMR II®)
90710	MMRV (ProQuad®)
90619	MenQuadfi® / MenACWY
90620	Bexsero®
90621	Trumenba®
90644	MenHibrix®
90733	Menomune®
90734	Menactra®, Menveo®
90670	Pneumococcal (PPSV23) / Prevnar 13®
90671	Pneumococcal conjugate (Vaxneuvance®)

1–10 of 11

1/2

Polio, Rotavirus, RSVCPT | HCPCSCovered

90713	Polio (IPV) (Ipol®)
90680	Rotavirus (Rotateq®)
90681	Rotavirus (Rotarix®)
96380	RSV vaccine administration
96381	RSV vaccine administration
90380	RSV vaccine (Beyfortus™)
90381	RSV vaccine (Beyfortus™)
90678	RSV vaccine (Abrysvo™)
90679	RSV vaccine (Arexvy™)
90683	RSV vaccine (mRESVIA®)

Varicella and ZosterCPTCovered

90716	Varicella (Varivax®)
90750	Zoster/Shingles (Shingrix®)

Adult BMI for intensive behavioral intervention

ThresholdBMI >= 30.0

Applicable services

Provider Requirements, Billing & Prior Authorization

Prior Authorization

BRCA genetic testing — prior authorization may apply

Prior authorization may be required for BRCA genetic testing services (procedure codes 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217).

Follow payer prior authorization rules when submitting BRCA genetic testing claims.

Note

New colorectal screening test procedure codes (0464U, 0537U)

New molecular stool test procedure codes have been added for colorectal screening: Cologuard Plus (0464U) effective 9/01/2025 and Shield (0537U) effective 1/01/2026; submit with the listed ICD-10 codes and follow payer submission rules.

0464U (Cologuard Plus) effective 9/01/2025; frequency once every 3 years, ages 45–85 (see procedure-specific instructions).
0537U (Shield™) effective 1/01/2026; frequency once every 3 years, ages 45 and older.

Policy Background and Rationale

This policy implements federal PPACA preventive benefit requirements by covering services recommended by the USPSTF with an A or B grade, vaccines recommended by ACIP, and preventive services supported by HRSA for pediatric care. Preventive services provided by network providers to eligible members are covered without member cost‑sharing for applicable non‑grandfathered plans when all preventive criteria and coding requirements are met.

Key Definitions and Terms

Preventive services

DefinitionServices performed on asymptomatic persons for screening or routine preventive care (e.g., USPSTF A/B services, ACIP immunizations)

Coverage conditionMust be reported as preventive to qualify for preventive benefit; network provider requirement affects cost sharing for non-grandfathered plans

ExamplesIncludes evidence-based USPSTF A/B recommendations, ACIP routine immunizations, HRSA/AAP Bright Futures pediatric screenings

Diagnostic services

DefinitionServices performed for evaluation of symptoms, abnormalities, or follow-up of abnormal findings — billed under diagnostic (non-preventive) benefits

ImplicationWhen a service is diagnostic it is not eligible for preventive benefit coverage and should be billed accordingly

Policy Revision History and Effective Dates

10/14/2025code_addition

Added HCPCS A4288 to Breast Pump Supplies (effective 10/1/2025).

9/18/2025code_addition

Included COVID-19 vaccine product code 91323 (effective 8/27/2025).

9/04/2025vaccine_and_code_updates

Updated 2025–2026 influenza vaccine listings and added molecular/STI/colorectal screening codes including 0455U (added to chlamydia/gonorrhea and PrEP/STI panels) and 0537U (Shield™ colorectal screening, effective 1/1/2026).

Policy Summary

PayerEmblemHealth

PolicyPreventive Services & Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeMultiple coding and frequency updates (additions/clarifications)

Effective DateVaries by item

Next Review DateN/A

Key ActionSubmit preventive services with the appropriate preventive ICD-10 diagnosis codes and procedure CPT/HCPCS codes so they are processed under the preventive benefit.

SourceLink

On This Page

Tomosynthesis: 1x/year ages 35+; Mammography: per screening frequency (1x/year as indicated)

See Breast imaging and tomosynthesis code group for specific CPT codes and comment that tomosynthesis is used in addition to mammography.

Ages 21-65; frequency 1 per 3 years

Pap Smear CPT codes and frequency are listed in the Pap Smear section.

Pregnancy screenings and panels: Pregnancy-related screenings (bacteriuria, blood count, obstetric panel including HIV, Hep B, Rh typing, pregnancy screening panel) are covered when billed with listed procedure codes and pregnancy ICD-10 codesFrequencies vary by test (unlimited or as indicated); append appropriate pregnancy ICD-10 codes per Appendix I

Pregnancy panels have specific frequency instructions (e.g., obstetric panel 1x/year; many pregnancy tests unlimited where specified).

PrEP counseling, administration and monitoring: PrEP counseling and administration (including cabotegravir J0739 and counseling codes G0011/G0013/G0012) and related monitoring labs are covered per listed procedure codes; cost share waived for USPSTF schedule of testingFrequency: counseling/administration unlimited; creatinine monitoring 3x/year; STI screening 4x/year; append Z29.81 for visits on/after 10/01/2023

PrEP visit documentation requirements and cost-share waiver are specified; additional testing codes and append codes listed.

Smoking cessation counseling codes are covered with listed procedure codes when billed with appropriate tobacco-use ICD-10 codesFrequency: up to 8x/year

See Smoking Cessation entry for ICD-10 mappings and frequency.

Sterilization and ancillary services: Sterilization procedures, ancillary services, and follow-up are covered when billed with listed procedure and ICD-10 codesFollow-up services limited to 2x/lifetime

Sterilization codes and follow-up limits are specified in the Sterilization section.

STI, HIV, syphilis, TB, vision screening, venipuncture: Screening services for STIs (syphilis), TB testing, vision screening in children, and specimen collection are covered when billed with the listed CPT/HCPCS codes and ICD-10 screening diagnosesFrequencies: Syphilis 4x/year; TB testing 1x/year; venipuncture 1x/year; vision screening 1x/year per pediatric age bands

See relevant sections for procedure codes and age/frequency specifics.

Immunizations: Vaccines listed and their administration codes are covered when provided per FDA/CDC age and frequency guidance and billed with the appropriate ICD-10 codesProvider must adhere to FDA/CDC schedules and age ranges specified per vaccine line items

Immunization administration codes and many vaccine CPT/HCPCS codes are listed; provider adherence to CDC/ACIP required to qualify for preventive benefit.

Multicomponent intensive behavioral interventions and preventive medicine individual counseling (e.g., CPT 99401–99404)

Frequency limitUp to 12 visits per year (preventive benefit instructions)

Stool occult blood frequency

FrequencyOnce every 3 years

Procedure codesStool occult blood: 82270, 82274

Age rangeAges 45-85 years (preventive benefit)

Cologuard / molecular stool test frequency

FrequencyOnce every 3 years

Procedure codesCologuard: 81528; Cologuard Plus: 0464U (effective 9/01/2025); Shield: 0537U (effective 1/1/2026)

Age rangeAges 45-85 years for Cologuard; Shield: Ages 45 and older

HIV screening frequency

FrequencyUnlimited

Procedure codesHIV screening: 86689, 87389, 86701-86703 (listed examples)

AgesAll ages (adolescents and adults)

Osteoporosis screening age/frequency (until 12/31/2025)

FrequencyEvery 23 months (effective until 12/31/2025)

Age thresholdAges 60 years and older

Procedure codesOsteoporosis screening: 76977, 77080, 77081

Osteoporosis screening age/frequency (effective 1/1/2026)

FrequencyEvery 24 months (effective 1/1/2026)

Age thresholdAges 65 years and older; Ages 40-65 with history of fragility fractures (ICD-10 Z87.310 AND Z13.820)

Procedure codesOsteoporosis screening: 76977, 77080, 77081

Pap smear frequency

Frequency1 time every 3 years

Age rangeAges 21-65

Procedure codesPap smear cytology: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175

Smoking cessation visits

Frequency8 visits per year

Procedure codesSmoking cessation counseling: 99401, 99402, 99403, 99406, 99407

AgesAll ages

Syphilis screening frequency

Frequency4 times per year

Procedure codesSyphilis screening: 86592, 86593

AgesAll ages

HPV coverage through age

Coverage through ageCoverage allowed through age 45 (until 46th birthday) — cost share applies for older ages

Procedure codesHPV vaccine codes: 90649, 90650, 90651

Standard age bandRoutine preventive benefit instructions list 9-26 years (ends on 27th birthday); extended coverage noted through age 45 with cost share

RSV age indications

Age indicationsBeyfortus™: Ages 0-24 months (ends on 2nd birthday); mRESVIA®: Ages 60 and older

Other guidanceOther RSV products (Abrysvo™, Arexvy™, etc.) follow CDC/ACIP guidance per vaccine-specific instructions

Administration codesRSV administration: 96380, 96381; product codes: 90380, 90381, 90678, 90679, 90683

Influenza age groups

Age groups vary by vaccineVaries by vaccine/product (examples: Ages 6 months and older; Ages 65+ for high-dose flu) — follow product-specific instructions

Examples90656/90657: Ages 6 months+ (varies by formulation); 90662 (High-dose Fluzone HD-IIV3): Ages 65+

Seasonal windowInfluenza vaccine product listing effective 8/01/2025–7/31/2026 for selected codes

Prior Authorization

Prior authorization — immunizations & maternity (no explicit PA listed)

No explicit prior authorization requirements are stated for the listed maternity global procedure codes or immunization administration codes in these sections; providers must still follow FDA/CDC immunization guidance when administering vaccines.

Maternity global codes listed: 59400, 59510, 59610, 59618 — no PA specified in this section.
Immunization administration codes (90460–90480 series) — no PA specified here; adhere to FDA/CDC age/frequency guidance.

Prior Authorization

Prior authorization statements not present in this section

There are no prior authorization statements in this portion of the preventive services policy.

If PA is required it will be specified on a service-by-service basis elsewhere in policy or by member-specific plan rules.

Denial Risk

Medicaid fee schedule — reimbursement and denial risk

Medicaid providers: EmblemHealth Medicaid plans reimburse only codes that appear on the Medicaid fee schedules; codes not on the fee schedule will be denied.

Verify code availability on the EmblemHealth Medicaid fee schedule before billing.

Billing Rule

Colorectal screening — operational coding & frequency

Operational note for colorectal screening: stool-based and molecular tests have frequency and age limits and new codes (0464U, 0537U) with effective dates — submit with the appropriate ICD-10 diagnosis codes to receive preventive benefit coverage.

Stool occult blood and molecular stool tests: frequency once every 3 years; Cologuard/Cologuard Plus effective dates and age limits apply (Cologuard Plus 0464U effective 9/01/2025).
Shield (0537U) effective 1/01/2026 — ages 45+ per code-specific instructions.
Include appropriate ICD-10 codes (e.g., Z12.10, Z12.11, Z12.12, Z80.0) when submitting.

Step Therapy

Step therapy — none specified for preventive services

No step therapy requirements are specified for preventive services in the policy chunks reviewed.

If step therapy requirements exist they will be documented separately or in specific drug/prescription policy sections.

Documentation Required

Report services as preventive (not diagnostic) to receive preventive benefit

Services must be reported as preventive (not diagnostic) to be considered under the preventive care benefit; if the service is furnished for diagnostic reasons it will be adjudicated under the non-preventive medical benefit.

Confirm member is asymptomatic and the service aligns with preventive intervals and guidelines before billing as preventive.
If prior abnormal findings, symptoms, or shortened-interval recommendations apply, bill under the diagnostic/non-preventive benefit.

Billing Rule

Required diagnosis and procedure coding for preventive screenings

Submit the listed ICD-10 diagnosis codes that correspond to the preventive screening (for example Z12.10, Z12.11, Z12.12, Z80.0, Z83.* for colorectal screening) together with the appropriate CPT/HCPCS procedure codes to receive preventive benefit coverage.

Ensure colon/colorectal screening claims include appropriate screening ICD-10 codes (e.g., Z12.10–Z12.12, Z80.0, Z83.71x) and the matching procedure code.
Pathology and CT colonography require the corresponding screening ICD-10 codes listed in the policy.

Billing Rule

PrEP visit coding — append Z29.81 for visits on/after 10/01/2023

All PrEP visits on or after 10/01/2023 must be appended with ICD-10 code Z29.81; earlier PrEP visits require specific code pairings as listed in the policy.

Append Z29.81 for all PrEP visits on/after 10/01/2023.
For visits before 10/01/2023 use the specified initial and subsequent visit code pairings (see policy chunk 41).

Documentation Required

RSV vaccination — adhere to CDC/ACIP age and frequency guidance

For RSV vaccines, providers must follow CDC/ACIP guidelines for age and frequency; RSV products listed include age-specific indications (e.g., Beyfortus™ ages 0–24 months, mRESVIA® ages 60+).

Adhere to CDC/ACIP recommendations when determining eligibility and timing for RSV vaccination.
Use the listed procedure and administration codes (e.g., 90380, 90381, 90678, 90679, 90683, administration codes 96380/96381) with appropriate ICD-10 diagnosis codes.

Denial Risk

Medicaid fee schedule denial risk — codes not on schedule will be denied

Codes that are not listed on the EmblemHealth Medicaid fee schedule will be denied for Medicaid members; verify presence on the Medicaid fee schedule before billing.

Medicaid providers must check the EmblemHealth Medicaid fee schedule prior to claim submission to avoid denials.

Denial Risk

Removed ICD-10 code Z01.818 — risk of non-acceptance after 6/1/2024

Do not use ICD-10 code Z01.818 for screening colonoscopy pre-procedure consultations after it was removed effective 6/1/2024; continued use may result in non-acceptance for preventive benefit submission.

Replace Z01.818 with the updated screening ICD-10 codes listed (e.g., Z12.10–Z12.12, Z80.0, Z83.*) when submitting pre-procedure consultation claims.

Denial Risk

Immunization billing — follow FDA/CDC age & frequency guidelines

Providers must adhere to FDA/CDC age and frequency guidelines for immunizations; failure to follow those guidelines could result in incorrect billing or denial of preventive benefit coverage.

Confirm patient age and vaccine-specific frequency limits before administering and billing vaccines.
Use the appropriate immunization administration and vaccine product codes as listed in the policy.

Billing Rule

Medicaid reimbursement limitation — verify fee schedule inclusion

EmblemHealth Medicaid plans reimburse only codes that appear on the Medicaid fee schedules; verify code reimbursement eligibility on the fee schedule prior to billing.

Failure to bill codes listed on the Medicaid fee schedule may lead to denial or nonpayment.

Note

Operational reminder — check revision history and effective dates

No additional background action required here; revision history includes multiple coding additions and effective dates — verify effective dates (e.g., new vaccine and test codes) before submitting claims.

Check revision history for effective dates (e.g., A4288 effective 10/1/2025, 0464U effective 9/1/2025, 0537U effective 1/1/2026).

ExamplesServices after abnormal screening results, shortened interval repeats, or evaluation of symptoms

Chlamydia/Gonorrhea combined testing

DefinitionCombined chlamydia and gonorrhea testing refers to molecular tests that detect both pathogens (0455U referenced for combined testing effective 1/1/2026)

Operational noteProcedure code 0455U is listed as effective 1/1/2026 for combined Chlamydia & Gonorrhea testing

Use in panelsCombined testing appears in STI screening panels and PrEP monitoring sections; follow effective date for submission

PrEP services

IncludesCounseling and administration (e.g., cabotegravir J0739) and monitoring/ongoing laboratory testing for PrEP

Frequency & codingPrEP counseling/administration: Frequency unlimited; monitoring creatinine: 82565/82575 (3x/year); STI screening: 4x/year (many codes listed)

Cost-share noteCost share waived for monitoring and testing when aligned with USPSTF schedule

Immunization administration

Administration codesImmunization administration CPT/HCPCS: 90460–90480 series (examples: 90460, 90461, 90471–90474, 90480)

Provider requirementProviders must adhere to FDA/CDC age and frequency guidelines when administering vaccines

ApplicationApplies to both adult and pediatric immunizations; COVID-19 administration code 90480 referenced

Preventive Benefit Instructions

InstructionPreventive Benefit Instructions attach age bands and benefit limits to each vaccine code indicating eligible member age groups and any cost-share notes

ExamplesHPV codes (90649–90651): routine 9–26 years, coverage allowed through age 45 with cost share; Influenza codes list age-specific instructions (e.g., 90662 for 65+)

Guideline adherenceSome vaccines (RSV, influenza) explicitly require following CDC/ACIP guidance; provider adherence affects correct billing and coverage

6/09/2025editorial_clarification

Revised ACIP link in the Introduction and clarified procedure codes and age/frequency limitations for preventive screening examination and well-child visits.

4/28/2025coverage_clarification

Clarified that EmblemHealth Medicaid plans only reimburse codes found on the Medicaid fee schedules.

4/01/2025code_addition_and_policy_update

Added Cologuard Plus lab test 0464U (effective 9/1/2025) and updated osteoporosis screening ICD-10 codes and frequency, including addition of screening for individuals with prior fragility fractures (effective 1/1/2026 updates noted).

1/15/2025brca_testing_update

Updated breast cancer (BRCA) genetic testing counseling/evaluation codes effective 1/1/2025 (added CPT 99401–99404; removed CPT 96040).

1/01/2024frequency_revision

Revised gestational diabetes screening frequency from 2x/year to 3x/year (effective 1/01/2024).

6/01/2024code_removalLatest

Removed ICD-10 code Z01.818 for screening colonoscopy pre-procedure consultations (removed effective 6/1/2024).