Women's Preventive Health Services — Well‑Woman Visits and Related Preventive Care (Delaware)
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Governs coverage and preventive benefits for women in Delaware under Highmark Blue Cross Blue Shield, including well-woman visits, counseling (STI, HIV, breastfeeding), screenings (HIV, gestational diabetes, HPV, urinary incontinence, anxiety), postpartum diabetes screening, contraceptive methods and breast pump coverage. Affects participating providers and covered members in Delaware.
No material clinical or coverage changes in this revision.
Coverage Criteria for Well-Woman and Related Services
Well-woman visit coverage
Covered when meeting routine preventive visit conditions:
Includes preventive age-appropriate services
STI and HIV counseling and screening
Covered preventive counseling and screening:
HIV screening: ages 15 and older at least once during lifetime; risk assessment/education beginning at age 13; screen all pregnant women at initiation of prenatal care
Breastfeeding counseling and breast pump coverage
Covered services related to breastfeeding:
Gestational and postpartum diabetes screening
Covered when ALL of the following apply:
Postpartum screening recommended for women with history of gestational diabetes who are not currently pregnant and without prior diabetes; initial postpartum testing ideally within first year (as early as 4-6 weeks); rescreen at least every 3 years for 10 years if initial negative
Urinary incontinence and anxiety screening
Preventive screening included during well-woman visits:
Urinary incontinence defined as involuntary leakage of urine
Included since 1/1/2021
Contraceptive services coverage
Covered when provided and FDA-approved:
Exception process available for nonformulary contraceptive drugs via provider medical necessity request; no initial 'fail first' required
Only FDA-approved contraception apps are reimbursable. Reimbursement for these apps must be submitted via a paper claim and include three documents: (1) under the claim section "DIAGNOSIS OR NATURE OF ILLNESS OR INJURY" enter "contraception app purchase", (2) the member's receipt of payment for the FDA-approved contraception app, and (3) the provider's prescription for the FDA-approved contraception app. Non–FDA-approved contraception apps are not covered.
CPT/HCPCS/ICD-10 Codes and Key Intervals
| 99201-99215 | E&M procedure codes for initial visit to determine pregnancy when accompanied by amenorrhea (N91.2) and pregnancy diagnosis |
| G0445 | STI counseling (up to two sessions per year) when accompanied by a routine diagnosis |
| 99401, 99402, 99403, 99404 | HIV counseling codes (up to two sessions per year) when accompanied by HIV counseling diagnosis |
| Z86.32, Z87.59 | History of gestational diabetes/no diabetes diagnosis coding guidance for postpartum screening |
Provider Billing, Documentation, and Authorization Actions
DME and Contraceptive Exception / Prior Authorization
Prior Authorization Required: Breast pumps and other Durable Medical Equipment (DME) related to lactation support require a prescription and may require an exception or prior authorization. Submit documentation that supports medical necessity per member benefits. Failure to obtain required prior authorization may result in claim denial or member cost-sharing.
- Breast pump DME requires a prescription
- Exception/prior authorization may be required per member benefits
- Include medical necessity documentation to support exception requests
Contraceptive Drug Exception Process
Contraceptive drug exceptions may be requested when a prescribed contraceptive is non‑formulary. An initial fail‑first (step therapy) is NOT required — provider‑determined medical necessity is sufficient. Complete the online exception request form and attach clinical justification. If approved, the drug is provided with a $0 member cost share.
- Complete the online formulary exception request form
- Provider-determined medical necessity is sufficient (no initial fail‑first required)
- When approved, prescribed drug is available with zero-dollar cost share
Required Documentation for DME and Contraception App Claims
Required documentation must accompany DME and contraception app claims to ensure proper processing and reimbursement. For DME (e.g., breast pumps) include the prescription, clinical notes supporting medical necessity, and any prior authorization or exception approval. For FDA‑approved contraception apps billed via paper claim include: (1) the claim form with "contraception app purchase" in the Diagnosis/Nature of Illness or Injury field; (2) the receipt of payment for the app; and (3) the provider prescription for the app. Attach all supporting clinical documentation when submitting exceptions or prior authorizations.
- DME: prescription, clinical notes supporting medical necessity, prior authorization/exception approval (if applicable)
- Contraception app paper claim: claim form with "contraception app purchase" in diagnosis field, receipt of payment, provider prescription
- Attach exception request form and any supporting clinical documentation
Eligibility Verification
Eligibility Verification: Providers must verify member eligibility and benefits at the time of service using Availity or ASC X12 270/271 transactions. Verification prior to service reduces risk of claim denial and ensures applicable coverage rules (including prior authorization requirements and cost‑share obligations) are known. Failure to verify eligibility may result in denied or unreimbursed services.
- Verify eligibility and benefits via Availity or 270/271 before providing service
- Confirm DME coverage rules and prior authorization requirements during verification
- Document verification efforts in the patient record to support claims
Background and Purpose
Well-woman visits provide age- and developmentally-appropriate preventive services including counseling and screening for sexually transmitted infections and HIV, mental health (including anxiety), urinary incontinence, gestational and postpartum diabetes, and reproductive health management. These visits are intended to deliver recommended preventive screening and counseling tailored to the member's age and clinical status.
Key Definitions
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