CurrentMass General Brigham Health PlanPolicy N/A

Preventive Services Reimbursement and Provider Payment Guidelines

Defines Mass General Brigham Health Plan's reimbursement approach for preventive services designated under the Affordable Care Act (USPSTF A/B, ACIP, HRSA, Bright Futures, and women's preventive services) and guidance for providers on coding, billing, and authorization; applies to plan members and in-network providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPreventive Services Reimbursement and Provider Payment Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnsure preventive services are billed with an appropriate preventive ICD-10 code in the primary diagnosis position and follow prior authorization requirements when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No member cost-shareUSPSTF A and B

Multiple updatesPreventive Grid updates

3Lines of business

Subject to editsClaims audits/edits

Preventive Service Coverage Criteria

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Preventive service coverage criteria

Coverage follows national preventive service recommendations and requires correct coding, adherence to member benefits, and compliance with provider contracts and authorization policies.

ALL of the following

ALL of the following
- Applicable recommendation sources
  - ALL of the following
    Reference: United States Preventive Services Task Force (USPSTF) A and B recommendations
  - ALL of the following
    Advisory Committee on Immunization Practices (ACIP) routine immunizations for children, adolescents, and adults
  - ALL of the following
    Health Resources and Services Administration (HRSA) recommended women's preventive services
  - ALL of the following
    Bright Futures preventive care and screens for children
- ALL of the following
  - USPSTF A and B recommended services are offered with no member cost share when administered by in-network providers
ALL of the following
- ALL of the following
  - Preventive services must be submitted with an ICD-10 code representing encounters not for treatment of illness or injury and the ICD-10 code must be placed in the first diagnosis position of the claim form
- ALL of the following
  - Claims should use the diagnosis codes listed in the plan's Preventive Service Grid or CPT/code guidance to be identified as preventive
- ANY of the following
  - If claims are submitted with diagnosis codes representing treatment of illness or injury (or other non-designated codes), the service will not be identified as preventive and will be paid under the member's normal medical benefits rather than preventive coverage
ALL of the following
- Covered services are defined by the member's benefit plan and member liability (copays, deductibles, coinsurance) is determined by that plan
- ALL of the following
  - Providers are reimbursed in accordance with the plan's network provider reimbursement or contracted rates; claims are subject to payment edits
ALL of the following
- Some services may require referral and/or prior authorization
  Refer to the plan's prior authorization resources and the Preventive Service Grid for service- and code-specific authorization requirements
ALL of the following
- Claims are subject to payment edits and audits; medical records may be requested and modifiers must follow CMS/CPT guidance

ALL of the following

See Mass General Brigham Health Plan Preventive Service Grid for CPT/code specifics and authorization details

Provider Authorization and Billing Actions

Prior Authorization

Check prior authorization/referral requirements before service

Various services and procedures may require referral and/or prior authorization; providers must check the plan's prior authorization requirements via the referenced prior authorization link and follow applicable CMS/CPT modifier and coding guidelines. Claims are subject to audit and medical records may be requested.

Locate referral/prior authorization requirements using the plan's prior authorization link referenced in the policy.
Use current CPT, HCPCS Level II, and ICD-10-CM procedure codes when requesting authorization.
Follow CMS or CPT guidance for required modifier use; incorrect modifiers can lead to payment differences or denials.
Be prepared to provide medical records if the claim is audited.

Key Definitions

Preventive services definition

DefinitionServices designated under ACA resources — USPSTF A/B recommendations, ACIP immunization recommendations, HRSA-supported comprehensive guidelines, Bright Futures periodicity schedule, and specified women's preventive services — that are covered without cost-sharing when provided in-network.

Primary sourcesU.S. Preventive Services Task Force (USPSTF) A and B recommendations; Advisory Committee on Immunization Practices (ACIP) immunization schedules; Health Resources and Services Administration (HRSA) guidelines; Bright Futures recommendations for pediatric preventive care; HRSA women's preventive health services guidance.

Cost-share noteUSPSTF A and B recommended services are offered with no member cost share when administered by in-network providers.

ApplicabilityCovered services are defined by the member's benefit plan and reimbursed per the plan's network provider reimbursement or contracted rates.

OpenPayer

Preventive Services Reimbursement and Provider Payment Guidelines

Preventive Service Coverage Criteria

Coding and Diagnosis Requirements

Provider Authorization and Billing Actions

Key Definitions