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Delaware annual behavioral health well check coverage criteria

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Defines coverage and reimbursement requirements for an annual behavioral health well check for Delaware members, including provider qualifications, required components of the visit, and mandated CPT reimbursement; applies to fully insured and certain state and Medicaid plans in Delaware.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDelaware annual behavioral health well check coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionBill the visit using the specified preventive CPT codes and document the encounter with the diagnosis 'annual behavioral health well check'.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Annual

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CurrentHighmark Blueshield NenyPolicy N/A

Delaware annual behavioral health well check coverage criteria

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Policy Summary

PayerHighmark Blueshield Neny

PolicyDelaware annual behavioral health well check coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionBill the visit using the specified preventive CPT codes and document the encounter with the diagnosis 'annual behavioral health well check'.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Annual

Coverage Criteria for Annual Behavioral Health Well Check

Coverage criteria for annual behavioral health well check

Covered when ALL of the following are met

Eligibility and provider: Member is covered under fully‑insured individual, fully‑insured group, State of Delaware Employee Group Health Insurance Program, or State Medicaid assistance plans as required by law

Applies to Delaware plans specified in statute.

Frequency: Service is provided once annuallyannual

Law requires an annual visit separate from the medical preventive visit.

Provider qualification: Visit is performed by a licensed mental health clinician with at minimum a master’s level degree

Minimum qualification specified by statute.

Visit content: Includes review of medical history, evaluation of adverse childhood experiences, and use of a group of developmentally appropriate mental health screening tools; may include anticipatory behavioral health guidance congruent with stage of life

Required and optional components per statute.

Billing and diagnosis: Billed using the diagnosis 'annual behavioral health well check' and reimbursed pre‑deductible at parity with the specified preventive CPT codes when used for other medical preventive services

Statutory reimbursement parity and pre‑deductible requirement.

This coverage is in addition to an annual preventive office visit with a medical care provider and does not replace the medical preventive visit. The law requires carriers to provide pre-deductible coverage for one annual behavioral health well check for members in the specified Delaware plans (fully‑insured individual, fully‑insured group, State of Delaware Employee Group Health Insurance Program, and State Medicaid assistance plans).

CPT and Billing Codes

Covered CPT Codes for annual behavioral health well checkCPTCovered

99381	Preventive medicine, infant (age under 1 year)
99391	Periodic preventive medicine re-assessment and management, infant (under 1 year)
99382	Preventive medicine, early childhood (ages 1 through 4 years)
99392	Periodic preventive medicine re-assessment and management, early childhood (1-4 years)
99383	Preventive medicine, late childhood (ages 5 through 11 years)
99393	Periodic preventive medicine re-assessment and management, late childhood (5-11 years)
99384	Preventive medicine, adolescent (ages 12 through 17 years)
99394	Periodic preventive medicine re-assessment and management, adolescent (12-17 years)
99385	Preventive medicine, adult 18-39 years
99395	Periodic preventive medicine re-assessment and management, adult 18-39 years

1–10 of 14

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Provider Billing, Documentation, and Operational Requirements

Billing Rule

Use specified preventive CPT codes and request reimbursement parity

Bill the annual behavioral health well check using one of the specified preventive CPT codes and seek reimbursement at parity with other medical preventive services. Use the listed CPT codes when submitting claims for this service.

Use one of the following CPT codes when billing: 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397.
Reimbursement must be at the same rate as when these CPT codes are used for other medical preventive services.

Step Therapy

No step therapy requirements specified

No step therapy or prior authorization requirements are specified for the annual behavioral health well check; the law requires coverage of a single annual visit without step therapy.

Key Definitions

inv-09: Definition — Annual behavioral health well check

Encounter definitionA designated encounter with a licensed mental health clinician (minimum master's level) using the diagnosis 'annual behavioral health well check'.

Required componentsIncludes review of medical history, evaluation of adverse childhood experiences, and use of developmentally appropriate mental health screening tools.

Optional componentsMay include anticipatory behavioral health guidance congruent with stage of life.

Provider qualificationMust be provided by a licensed mental health clinician with at minimum a master's level degree.

Billing diagnosisMust be billed using the diagnosis 'annual behavioral health well check'.

Level of Care — Outpatient

Preventive Behavioral Health Screening

Preventive behavioral health screening

Screening tools: Use a group of developmentally appropriate mental health screening tools during the visit

Specified in statute as a required component of the well check.

Visit Limits and Frequency

inv-12: Annual behavioral health well check — Visit limits

Frequency limitOne annual behavioral health well check per 12-month period (annual).

Coverage timingPre-deductible coverage as required by law.

Applicable plansFully‑insured individual, fully‑insured group, State of Delaware Employee Group Health Insurance Program, and State Medicaid assistance plans as required by statute.

Care settingOutpatient preventive single-encounter visit; not a substitute for the medical preventive visit.

Background and Rationale

Routine behavioral health screening and early intervention can identify adverse childhood experiences and emerging mental health concerns that, if unaddressed, increase risk of later mental illness, substance use disorders, and higher societal costs. The statutory annual behavioral health well check is intended to support early identification by requiring a designated encounter with a licensed mental health clinician (minimum master’s level) that includes review of medical history, evaluation of adverse childhood experiences, and the use of developmentally appropriate mental health screening tools; it may also include anticipatory behavioral health guidance appropriate to the member’s stage of life.