Women's Preventive Health Services Addendum (Preventive Services for Women)
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Defines coverage, coding, and programmatic details for preventive services for women (well-woman visits, counseling, screenings, contraception, lactation support, and related services) applicable to Highmark Delaware members under the Highmark Northeastern New York preventive health addendum.
No material clinical or coverage changes in this revision.
Coverage Criteria
Well-woman visits
Covered preventive services and visit frequency
Initial visit to determine pregnancy defined as E&M procedure codes 99201-99215 when accompanied by amenorrhea (N91.2) or pregnancy diagnosis.
HIV/STI Counseling and Screening
HIV and STI screening/counseling
Up to two counseling sessions per year with codes 99401–99404 or G0445 when accompanied by appropriate routine diagnoses.
Breastfeeding counseling and supplies
Breastfeeding support
Breast pumps are DME requiring a prescription; covered HCPCS include E0602 (manual), E0603 (electric) and supplies A4281–A4286 (A4287 effective 1/1/2024).
Contraceptive and sterilization services
Contraception coverage
Members may request coverage for an alternative version if the covered method is unavailable or medically inadvisable; groups qualifying as religious employers may elect a separate rider. Coverage applies even if prescription drugs are not otherwise covered under the policy.
Gestational and postpartum diabetes screening
Gestational and postpartum diabetes screening
Use CPT screening codes 82947, 82950, 82951, 82952 or 83036 when accompanied by a pregnancy diagnosis or postpartum diagnosis and a history code Z86.32 or Z87.59 as appropriate.
Coding guidance: when no pregnancy or diabetes diagnosis, use Z86.32 or Z87.59 with procedure codes; documented frequency guidance references 2 annually in coding guidance for programmatic tracking.
Behavioral health and urinary incontinence screening
Urinary incontinence and anxiety screening
Urinary incontinence is defined as involuntary leakage of urine (e.g., with coughing or sneezing).
Recommendation from the Women’s Preventive Services Initiative as incorporated into the preventive services addendum.
Grandfathered employer group health plans may not be subject to all provisions of the Affordable Care Act. As stated in the addendum, benefits that implement PPACA-required preventive services may not apply to grandfathered plans unless the employer elects coverage. Providers and billing staff should confirm plan status and benefit applicability when scheduling or billing preventive services to determine whether cost-sharing or coverage differences apply.
Coding and Billing
| Z86.32 | History of gestational diabetes |
| Z87.59 | Personal history of other endocrine, nutritional and metabolic disease |
Provider Actions and Billing Rules
Contraceptive formulary exception process
Your provider may request a formulary exception (prior authorization) for a prescribed nonformulary contraceptive drug based on medical necessity by completing the online Pharmacy Prior Authorization request form. When approved, the prescribed drug will be available with a zero-dollar member cost share.
- Provider completes online Pharmacy Prior Authorization / exception request form.
- Approval grants the prescribed nonformulary contraceptive with $0 cost share.
Contraception step therapy
Initial 'fail first' (step therapy) is not required for contraceptive drugs. A provider-determined medical necessity justification alone is sufficient when requesting an exception; the provider may note a prior formulary trial or failure but it is not required.
- No initial 'fail first' required — provider medical necessity suffices.
- Provider may document previous formulary trial but it is optional.
Reimbursement requirements for FDA‑approved contraception apps
Only FDA‑approved contraception apps (not part of the 18 FDA method categories) that are available for download to a mobile device are reimbursable. Reimbursement is processed via paper claim and requires a provider prescription and proof of payment.
- Submit a paper Medical Claim Form and write "contraception app purchase" in the DIAGNOSIS OR NATURE OF ILLNESS OR INJURY section.
- Include the receipt showing payment for the FDA‑approved contraception app.
- Include a provider prescription for the specific FDA‑approved contraception app.
Check member eligibility and benefits
Always verify member eligibility and benefits before providing services to avoid uncovered services or unexpected member cost‑share. Check via Availity Eligibility & Benefits or the ASC X12 270/271 Eligibility Benefits Inquiry and Response transactions each time a member presents for service.
- Use Availity Eligibility & Benefits function for member checks.
- Or use ASC X12 270/271 Eligibility Benefits Inquiry and Response transactions.
- Failure to confirm eligibility may result in services not being covered or unexpected member cost‑share.
Definitions
Background
This addendum defines Highmark Delaware coverage for a core set of women’s preventive services including well-woman visits (up to 4 visits per year—typically two with a primary care provider and two with an OB/GYN when billed with routine diagnosis codes), HIV/STI counseling and screening (risk assessment beginning at age 13 and at least one lifetime HIV screening for ages 15+; screening in pregnancy at initiation of prenatal care with rescreening as indicated), breastfeeding support and equipment (comprehensive lactation services and coverage for rental or purchase of one breast pump per pregnancy, DME requiring a prescription, with specified HCPCS codes), contraceptive methods and sterilization services (coverage for all FDA‑approved methods without cost‑sharing and an exception process for nonformulary drugs based on provider‑documented medical necessity), and related services such as gestational and postpartum diabetes screening (screen at first prenatal visit and at 24–28 weeks; initial postpartum testing ideally within the first year, as early as 4–6 weeks) plus screening for urinary incontinence and anxiety per guideline recommendations.
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