Modifiedharvard pilgrim health carePolicy N/A

Preventive Care Services coverage (Tufts Health Direct preventive services grid) - Coverage Criteria

Defines Tufts Health Direct preventive care services that are covered (no in-network cost-sharing) when delivered by in-network providers and lists applicable procedure and diagnosis codes and comment rules. Affects providers submitting preventive service claims for Tufts Health Direct members.

Policy Summary

Payerharvard pilgrim health care

PolicyPreventive Care Services coverage (Tufts Health Direct preventive services grid) - Coverage Criteria

Policy CodePolicy N/A

Change TypeCode additions, removals, and age criteria clarifications

Effective DateN/A

Next Review DateN/A

Key ActionBill immunization administration and counseling codes with ICD-10 code Z23 or Z71.85 in the primary position to receive the preventive benefit.

SourceLink

POLICY UPDATE CHANGES

Added multiple new immunization and administration procedure codes (e.g., 90382, 90612, 90613, 90631, 90635, 91323; later removal of 90631).

Updated numerous code additions and edits across preventive services (e.g., changes to immunizations, screening, and administration codes).

Added age criteria for certain vaccine codes (examples: 90380, 90381, 90644, 90678, 90679, 90683, 90734).

~100+listed vaccine CPT codes and formulations

50-80lung cancer screening age range

65-75AAA screening (men)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

40-75statin prevention age range

Multiplepublication history code updates

Coverage Criteria and Conditions

Preventive Benefit Adjudication

Covered when billed as preventive with correct diagnosis coding and provider:

Preventive service adjudication: Service is covered as Preventive Care when performed by an in-network provider and billed with a listed preventive diagnosis code in the primary position; services performed for diagnostic purposes will be adjudicated under the non-preventive medical benefit.

Modifier 33 may be reported but is not used in benefit determinations unless specifically indicated.

Service-specific Coverage

Covered preventive services with service-specific constraints:

AAA Screening: Abdominal aortic aneurysm (AAA) screening (CPT 76706) is covered once per lifetime for men ages 65–75 with a prior history of smoking when billed with one of the listed ICD-10 diagnosis codes; coverage ends on the 76th birthday.once per lifetime

Billed with one of the listed ICD-10 codes.

Colorectal Cancer Screening: Screening colonoscopy is payable as preventive when billed with one of the listed ICD-10 diagnosis codes; excludes inpatient and emergency department settings and the diagnosis must be billed in the primary position. Use CPT 00812 for screening colonoscopy billing.

Virtual CT colonography (74263) covered when medically necessary.

Lung Cancer Screening: Low-dose CT lung cancer screening (CPT 71271) is covered for adults ages 50–80 with a ≥20 pack-year smoking history who currently smoke or quit within the past 15 years when billed with one of the listed ICD-10 codes.age 50-80, >=20 pack-year

Rx / Prior Authorization Conditions

Covered preventive interventions tied to Rx or prior auth requirements:

BRCA Testing: BRCA testing and associated genetic counseling/evaluation are payable as preventive when billed with one of the listed diagnosis codes in the primary position and require prior authorization.

BRCA testing CPT codes listed in the coding grid (prior authorization required).

Statins: Statin drugs for primary prevention of cardiovascular disease are covered for adults ages 40–75 with cardiovascular risk factors when the member has pharmacy (RX) coverage; low-to-moderate dose statins apply and are subject to RX benefit rules and quantity limits.ages 40-75

Must have RX coverage; quantity/coverage subject to Rx benefit rules.

Preventive Immunization Coverage

Covered when ALL of the following are met:

FDA and ACIP criteria: Vaccine is considered covered if it is FDA approved and has an explicit ACIP recommendation for routine use published in the CDC MMWR; implementation will typically occur within 60 days after MMWR publication.implementation typically within 60 days after MMWR publication

Immunizations that fall under exclusions in the Certificate of Coverage remain excluded despite meeting these criteria.

Administration/Counseling Billing Criteria

Billing requirements for administration and counseling codes:

Diagnosis code requirement: Immunization administration and immunization counseling CPT codes must be billed with ICD-10 code Z23 (or Z71.85 for counseling when immunization not given) in the primary position for the preventive benefit to apply.primary position

Applies to administration codes (e.g., 90460–90474, 90480–90484) and counseling codes listed in the coding grid.

Screening Tests Coverage Conditions

Certain screenings covered when billed with specific codes/diagnoses:

Syphilis screening is covered when billed with CPT codes 86592, 86593, or 86780 and one of the listed ICD-10 diagnosis codes (e.g., Z00.00, Z00.01, prenatal/surveillance codes); coverage also applies when billed with a Supervision of Pregnancy ICD-10 diagnosis code.must use listed CPT and ICD-10 codes

See coding grid for full list of acceptable ICD-10 codes.

Tuberculin/Latent TB screening: Tuberculin skin test (CPT 86580) and TB IGRA tests (CPT 86480, 86481) are covered for indicated ages and risk groups; pediatric tuberculin testing is specified for high-risk children and latent TB screening is recommended for adults at increased risk when billed with the listed ICD-10 codes.age/risk based

High-risk children and adults at increased risk per policy comments.

Covered preventive immunizations

Covered immunizations and administration services as listed

Immunization coding and indications: Each vaccine product is covered and listed with its CPT/HCPCS code and, where provided, brief age or risk-group indications (for example: PCV21 indicated for adults 19–64 with certain risk conditions and adults 65+; PPSV23 routine for adults 50+). Use the specific product code and follow any age/risk indications when billing.

Use the specific CPT/HCPCS code and any age indications from the coding grid when submitting claims.

Colorectal cancer screening services are payable as preventive only when billed with one of the listed ICD‑10 diagnosis codes and must be billed with that diagnosis in the primary position. Screening colonoscopy should be billed with 00812. The preventive benefit explicitly excludes inpatient and emergency room (ER) settings for colorectal screening.

An immunization is considered covered only if it does not fall under an exclusion in the member’s Certificate of Coverage and the vaccine meets the policy’s product criteria (FDA approval and explicit ACIP routine‑use recommendations published in the MMWR). Immunizations that are excluded by the Certificate of Coverage are not covered even if other policy criteria would otherwise be met.

The publication history documents removal and deprecation of procedure codes over time; examples include the addition of various immunization codes on 07/16/25 followed by the removal of code 90631 on 08/14/25, and earlier removals such as deletion of G0106, G0120, and G0122 from the Colonoscopy listing. Providers must use the current code list in the policy and the most recent publication history when submitting claims.

When a service is performed for diagnostic purposes it will be adjudicated under the applicable non‑preventive medical benefit. Such services should not be billed as preventive; diagnostic use may result in denial of the preventive benefit.

No explicit Not Medically Necessary (NMN) statements are present in the cited policy chunks. The policy does, however, state adjudication rules distinguishing preventive versus diagnostic services and lists publication history entries that document code and policy updates which could affect coverage determinations.

Procedure, Diagnosis, and Vaccine Codes

Abdominal Aortic Aneurysm ScreeningCPTCovered

76706

Abdominal aortic aneurysm screening (ultrasound)

BRCA TestingCPTCovered

81162	BRCA testing
81163	BRCA testing
81164	BRCA testing
81165	BRCA testing
81166	BRCA testing
81167	BRCA testing
81212	BRCA testing
81215	BRCA testing
81216	BRCA testing
81217	BRCA testing

Breast Cancer ScreeningsmixedCovered

77067	Screening mammography
G0279	Unspecified mammography HCPC

Autism Screening / Developmental & Behavioral AssessmentCPTCovered

96110	Autism screening / developmental assessment
96127	Brief emotional/behavioral assessment

Bacteriuria ScreeningCPTCovered

81000	Urinalysis
81007	Urinalysis

Colorectal Cancer ScreeningmixedCovered

00812	Screening colonoscopy
G0104	Colorectal cancer screening HCPC

Contraception - Drugs, Devices, SterilizationmixedCovered

11976	Contraceptive management
J7300	IUD HCPC

Diabetes Mellitus ScreeningCPTCovered

82947	Glucose; quantitative, blood (e.g., fasting)
83036	Hemoglobin A1c

High Blood Pressure Screening - MonitorsmixedCovered

93784	Ambulatory blood pressure monitoring
A4660	Home blood pressure monitor

Lung Cancer Screening (LDCT)CPTCovered

71271

Low-dose CT for lung cancer screening

Osteoporosis Screening (Bone Density)mixedCovered

77080	Bone density - DXA
G0130	Bone density screening HCPC

Tuberculosis / Tuberculin TestingCPTCovered

86580	Tuberculin skin test
86480	TB blood test

Preventive counseling and visit codesCPTCovered

99406	Tobacco use prevention counseling
99407	Tobacco use prevention counseling
G0296	Tobacco cessation counseling
G0438	Annual wellness visit, initial
G0439	Annual wellness visit, subsequent

TB testing and venipunctureCPTCovered

86580	Tuberculin test
86480	TB screening (IGRA)
36415	Venipuncture
36416	Venipuncture

Preventive Immunization CPT CodesCPTCovered

90460	Immunization administration through 18 years; first or only component with counseling
90461	Immunization administration through 18 years; each additional component
90471	Immunization administration; one vaccine (intramuscular/subcutaneous)
90472	Immunization administration; each additional vaccine
90473	Immunization administration by intranasal or oral route; one vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine
90480	Immunization administration; SARS-CoV-2 single dose (IM)
90481	Each additional component administered for SARS-CoV-2 vaccine
90482	Immunization counseling when immunization not administered; 3-10 minutes
90483	Immunization counseling when immunization not administered; >10-20 minutes

1–10 of 64

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ICD-10 Diagnosis Codes referencedICD-10

Z23	Encounter for immunization
Z71.85	Immunization counseling (when immunization not given)
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings

Syphilis Screening Procedure CodesCPTCovered

86592	Syphilis test
86593	Syphilis test
86780	Treponema pallidum serology

Immunizations and Administration CodesmixedCovered

90677	Pneumococcal conjugate vaccine, 20 valent (PCV20)
90678	Respiratory syncytial virus vaccine, preF, subunit, bivalent
90679	Respiratory syncytial virus vaccine, preF, subunit, adjuvanted
90680	Rotavirus vaccine, pentavalent (RV5), 3-dose schedule (Rotateq)
90681	Rotavirus vaccine, human, attenuated (RV1), 2-dose schedule
90682	Influenza virus vaccine, quadrivalent (RIV4) (Flublok)
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles
90684	Pneumococcal conjugate vaccine, 21 valent (PCV21)
90685	Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL (Fluzone)
90686	Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL

1–10 of 59

1/6

AAA screening age/eligibility

Age & frequencyMen ages 65-75 once in a lifetime (screening ends on 76th birthday)

Eligibility conditionPrior history of smoking required

Procedure codeCPT 76706 (abdominal aortic aneurysm screening ultrasound)

Provider Billing, Documentation, and Authorization Requirements

Prior Authorization

Prior Authorization Required for BRCA Testing

BRCA testing requires prior authorization to be payable as preventive when billed with one of the listed diagnosis codes in the primary position.

BRCA testing prior authorization: BRCA testing payable as preventive only when billed with one of the listed ICD-10 diagnosis codes in the primary position; BRCA testing requires prior authorization.

Prior Authorization

Prior Authorization — Vaccines and Related Products

No explicit prior authorization language is present for the listed vaccines in this section; codes for newer RSV and PCV vaccines are provided for billing reference. Note that some injectable medications added under HIV/HIV PrEP (J0738, J0752) have prior authorization requirements per the October 2025 update.

Immunization codes added (e.g., PCV20 90677, RSV vaccines 90678–90679, RSV monoclonal antibody administration 96380/96381) are listed for billing reference.
Prior authorization note: J0738 and J0752 under HIV/HIV PrEP require prior authorization (10/01/25 update).

Policy Context and Guiding Recommendations

This preventive services grid aligns covered services with recommendations from the USPSTF, Bright Futures, AAP, CDC and HRSA and maps each recommended service to the specific procedure and diagnosis codes to be used for preventive adjudication. For immunizations the policy requires that vaccines be FDA approved and have explicit ACIP routine‑use recommendations published in the MMWR (implementation typically within 60 days). The grid also specifies required billing documentation: preventive diagnosis codes must be in the primary position, and immunization administration/counseling codes must be billed with ICD‑10 code Z23 (or Z71.85 where applicable) in the primary position. Specific vaccine products and administration codes are listed with their CPT/HCPCS codes for billing.

Key Definitions

Preventive Care Services

DefinitionPreventive Care Services are services identified based on USPSTF, Bright Futures, AAP, CDC, and HRSA recommendations that, when rendered by an in-network provider, are covered with no member cost-sharing

Provider & billing requirementService must be performed by an in-network provider and billed with a listed preventive diagnosis code in the primary position

Sources of recommendationsUSPSTF, Bright Futures, AAP, CDC (ACIP), and HRSA

Modifier 33 noteModifier 33 may be reported but is not used in benefit determinations unless specifically indicated in comments

Primary position diagnosis

DefinitionPrimary position diagnosis = the diagnosis code placed in the primary position on the claim

Publication and Policy Change Log

2026-01-01policy_creation_history_window

(From publication history list covering 01/01/25–05/01/26) Multiple publication history entries document code additions, removals, and age-criteria updates to immunization and preventive service codes between 01/01/25 and 05/01/26; see individual dated entries below.

2025-07-16codes_added

Added immunization procedure codes 90382, 90612, 90613, 90631, 90635 and SARS‑CoV‑2 code 91323 under Immunizations.

2025-08-14code_removed

Removed immunization procedure code 90631 (previously added on 07/16/25).

Policy Summary

Payerharvard pilgrim health care

PolicyPreventive Care Services coverage (Tufts Health Direct preventive services grid) - Coverage Criteria

Policy CodePolicy N/A

Change TypeCode additions, removals, and age criteria clarifications

Effective DateN/A

Next Review DateN/A

Key ActionBill immunization administration and counseling codes with ICD-10 code Z23 or Z71.85 in the primary position to receive the preventive benefit.

SourceLink

On This Page

Lung cancer screening eligibility

Age rangeAdults aged 50-80 years

Smoking history threshold≥20 pack-year history

Tobacco statusCurrent smokers or those who quit within the past 15 years

Procedure codeCPT 71271 (low-dose CT for lung cancer screening)

HPV age coverage

General reimbursed age rangeHPV vaccines reimbursed for ages 9-26 for several products

Series completion noteWhen the 3-dose series is begun by age 26, subsequent injections are covered into age 27 to complete the series

Gardasil9 (90651) coverageCoverage for Gardasil9 is limited to ages 9-45

Pneumococcal PCV15/PCV20/PCV21 recommendations

PCV15/PCV20 listedPCV15 and PCV20 are included in the preventive immunization list (e.g., PCV20 = CPT 90677)

PCV21 recommendationPCV21 (CPT 90684) recommended for adults aged 19-64 with certain risk conditions and for adults 65 years and older

Administration routeIntramuscular use per vaccine descriptions

Age indications (examples)

PCV21 indication exampleAdults aged 19-64 years with certain risk conditions for pneumococcal disease; adults aged 65 years and older are also recommended (CPT 90684)

PPSV23 routine usePPSV23 (CPT 90732) recommended for adults aged 50 years and older (routine)

PPSV23 risk-group usePPSV23 for adults aged 19-49 years with certain risk conditions

Denial Risk

Diagnostic vs Preventive Billing

When a service is performed for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefit and may not be paid as preventive.

Diagnostic vs Preventive billing: If the service is diagnostic rather than preventive, file under the non‑preventive benefit — preventive coverage may be denied.

Billing Rule

Screening Billing Linkage

Some preventive screening services are covered only when billed with specific CPT procedure codes and the listed ICD-10 diagnosis codes; ensure claims include the required procedure and diagnosis combination.

Example — Syphilis Screening: CPT 86592, 86593, 86780 must be billed with one of the listed ICD-10 diagnosis codes (e.g., Z00.00, Z11.2) or a Supervision of Pregnancy ICD-10 code for the preventive benefit to apply.
Example — Tuberculin and Tuberculosis screening: CPT 86480/86481/86580 require listed ICD-10 codes for preventive adjudication.

Denial Risk

Coding Mismatch Risk — Keep Codes Current

Publication history shows multiple code and policy updates; providers should keep coding current to avoid claim denials due to mismatches between billed codes and the policy's supported code lists.

Coding mismatch risk: recent updates added and removed numerous CPT/HCPCS/ICD-10 codes (see publication history).
Action: Verify that the CPT/HCPCS and ICD-10 codes you submit match the latest policy code lists and effective dates.

Billing Rule

Billing Position and Modifier 33

All diagnosis codes for preventive, screening, counseling, or wellness should be billed in the primary position; Modifier 33 may be reported but is not used to determine benefit applicability except where specifically noted.

Billing position: List the preventive ICD-10 diagnosis in the primary position on the claim for preventive adjudication.
Modifier 33: You may append Modifier 33 where applicable, but benefit determinations rely on the procedure and diagnosis lists unless comments indicate otherwise.

Billing Rule

Required Diagnosis Coding for Immunizations

Immunization administration and immunization counseling codes must be billed with ICD-10 code Z23 (immunization) or Z71.85 (immunization counseling when vaccine not given) in the primary position for the claim to be considered preventive.

Required diagnosis coding: Use Z23 in the primary position for preventive immunization administration.
If counseling only (vaccine not administered), bill with Z71.85 in the primary position.
Examples: 90481–90484 immunization counseling codes must be billed with Z23 or Z71.85 as primary.

Documentation Required

Administration Coding and Documentation

Use the listed administration codes for vaccine and monoclonal antibody administration and for in‑home vaccine administration; ensure the appropriate administration code accompanies the vaccine product code on the claim.

Common administration codes: G0008 (influenza), G0009 (pneumococcal), G0010 (in‑home administration of pneumococcal/influenza/hepatitis B/COVID-19), 96380/96381 (RSV monoclonal antibody administration).
Immunization counseling codes: 90481–90483 (counseling when vaccine not administered) must also be billed with Z23 or Z71.85 in primary position.
Ensure administration codes are submitted with the matching vaccine CPT/HCPCS (e.g., 90677 PCV20, 90678–90679 RSV vaccines).

Billing Rule

Statin Prescription Requirement

Statin drugs for adult prevention of cardiovascular disease require pharmacy (RX) coverage; low to moderate dose statins are covered for adults ages 40–75 with CVD risk factors.

Statin Rx requirement: Coverage applies only when the statin has RX benefit coverage.
Covered population: Adults 40–75 years with CVD risk factors; low to moderate dose regimens.

Billing requirementPreventive services diagnosis codes should be billed in the primary position for preventive benefit adjudication

Consequence of incorrect positionServices billed for diagnostic purposes will be adjudicated under non-preventive medical benefits

Covered Immunization

Coverage criteriaAn immunization is considered covered if it is FDA approved and has explicit ACIP routine-use recommendations published in the MMWR (implementation typically within 60 days)

Exclusions caveatImmunizations falling under Certificate of Coverage exclusions are not considered covered even if other criteria are met

Documentation requirementUse ACIP recommendations published in the MMWR to confirm routine-use status

ICD-10 for Immunizations

Designated ICD-10 codeZ23 is the designated ICD-10 code for immunizations (Encounter for immunization)

Counseling codeZ71.85 may be used for immunization counseling when immunization is not given

Billing linkageZ23 or Z71.85 must be billed in the primary position for certain administration and counseling CPT codes (e.g., 90480-90484, 90482-90483)

PCV20 / PCV21

PCV20 codePCV20 is listed (CPT 90677)

PCV21 code & notePCV21 is listed (CPT 90684) with indication for adults 19-64 with certain risk conditions and adults 65+

Vaccine typeThese are pneumococcal conjugate vaccines for intramuscular use

SARS-CoV-2 vaccines

Multiple SARS-CoV-2 productsSeveral SARS-CoV-2 vaccine procedure codes are listed (e.g., 91304, 91318-91323)

Product examples91318–91320 and 91321–91323 correspond to specific manufacturer formulations and dosages (Pfizer-BioNTech, Moderna, Novavax) as listed

Administration contextSARS-CoV-2 vaccine codes are listed alongside administration guidance in the immunization grid

2025-04-01codes_and_age_criteria_updated

Added procedure codes 90611 and 90622 under Immunizations and specified age criteria for 90670, 90671, 90677, 90684, and 90732; also added diagnosis code Z13.32 and Postpartum Depression Screening to Health Risk Assessment title.

2025-03-01codes_added_and_removed_and_age_criteria

Added procedure code 90624, removed codes 90630 and 90654, and added age criteria for codes 90380, 90381, 90644, 90678, 90679, 90683, and 90734 under Immunizations.

2025-02-01code_updates

Updated chlamydia screening code 84790 to 87490 and updated colonoscopy-related diagnosis code formatting (Z86.010 to Z86.0100); added contraception diagnosis codes Z30.44 and Z30.45.

2025-01-01policy_created_and_codes_changedLatest

New policy created (archiving prior Preventive Services Payment Policy); multiple code edits including changing 96040 to 96041 under BRCA, adding 87626 to Cervical Cancer Screening, edits to colonoscopy bowel preparation language, HIV screening code updates (added Q0521; removed Q0516–Q0520), and additions to Immunizations (90593, 90619) among other administrative edits.

Material changes in the publication history include the addition of multiple new immunization and administration procedure codes across 2025 and 2026 (for example entries on 07/16/25 added codes such as 90382, 90612, 90613, 90631, 90635, 91323). The record also shows subsequent edits and removals (for example, 90631 was removed on 08/14/25) and other administrative code updates noted throughout the publication history.

The publication history provides specific examples and dates of deprecated or removed codes. Notable entries include removal of procedure and HCPCS codes from coding grids (for example, removal of G0106, G0120, G0122 from Colonoscopy in a 01/01/26 edit), and the addition then later removal of immunization code 90631 (added 07/16/25; removed 08/14/25). Providers should reference the publication history and the current policy code tables when billing.