CurrentMass General Brigham Health PlanPolicy N/A

Preventive Care Provider Payment Guidelines

Governs reimbursement and billing rules for preventive services (USPSTF A/B, ACIP immunizations, Bright Futures, HRSA women's services) for Mass General Brigham Health Plan members and in-network providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPreventive Care Provider Payment Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit preventive services with a preventive ICD-10 diagnosis code in the first position to ensure claims are processed as preventive care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

oneannual preventive physical exam reimbursed per calendar year by PCP

USPSTF A and Bpreventive services covered with no member cost share when in-network

onesecond annual preventive physical exam not reimbursed

multiplePreventive Grid updates listed

Preventive Service Coverage Rules

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Preventive coverage and billing rules

Mass General Brigham Health Plan coverage parameters for preventive services

USPSTF A and B recommended services are offered with no member cost share when provided in-network.

Immunizations recommended by ACIP are covered as preventive services.

Preventive services for children per Bright Futures and newborn screening panels are included.

Preventive care and screenings provided for women supported by HRSA are included.

Providers are reimbursed in accordance with the plan's network provider reimbursement or contracted rates; claims are subject to payment edits and covered services are defined by the member's benefit plan.

Preventive services must be submitted with an ICD-10 code representing an encounter for preventive care in the first diagnosis position; submission with treatment/illness diagnosis codes will cause claims to be processed as medical benefits rather than preventive coverage.

Mass General Brigham Health Plan reimburses one annual preventive physical examination per calendar year when performed by the member's primary care provider.

Not reimbursed

A second annual preventive physical examination performed within the same calendar year is not reimbursable.
Annual preventive physical examinations performed by the member's OB-GYN who is not the member's primary care provider are not reimbursed under the supplemental benefit; OB-GYNs should bill only Medicare-covered services and members should be referred to their primary care provider for comprehensive preventive care.

Refer to the Mass General Brigham Health Plan Preventive Grid for CPT codes and to USPSTF, ACIP/CDC, HRSA, and Bright Futures resources for recommended services and authorization requirements.

Diagnosis and Billing Codes

Diagnosis coding for preventive servicesICD-10Covered

ICD-10 (preventive encounter codes)

Preventive care services must be submitted with an ICD-10 code representing an encounter for preventive care in the first diagnosis position; using treatment/illness codes may cause claims to be processed as medical benefits.

In‑network cost share for USPSTF A/B

Cost share for USPSTF A/B servicesNo member cost share when USPSTF A and B recommended services are administered by in-network doctors and hospitals.

Applies when delivered in-networkRequirement applies only when services are provided by in-network doctors and hospitals; out-of-network care may have member liability per benefit plan.

Reimbursement basisProviders are reimbursed according to the plan's network provider reimbursement or contracted rates; claims subject to payment edits.

Member liability exceptionsMember liability amounts (copayments, deductibles, co-insurance) are applied based on the member's benefit plan for services not meeting in-network USPSTF A/B criteria.

Prior Authorization, Referrals, and Provider Requirements

Prior Authorization

Check prior authorization and referral requirements

Various services and procedures require referral and/or prior authorization. Referral and prior authorization requirements can be located via the plan's referenced resources; providers should consult the Mass General Brigham Health Plan Preventive Grid for CPT codes that have specific authorization requirements. Follow line-of-business guidance for applicability (MassHealth and Commercial: entire policy applies; Medicare Advantage: refer to CMS Medicare Preventive Services Tool).

Locate specific prior authorization and referral requirements on the Mass General Brigham Health Plan Preventive Grid.
Use current CPT, HCPCS Level II, and ICD-10-CM procedure codes as published by AMA, CMS, and AHA when submitting requests.
For Medicare Advantage members, check the CMS Medicare Preventive Services Tool (MLN006559) for applicable guidance.

Preventive Services Defined

Preventive services defined

Scope of preventive servicesServices designated as preventive care include periodic well visits, routine immunizations, and certain designated screenings.

Authoritative recommendation sourcesIncludes services identified by USPSTF A and B recommendations, ACIP vaccine recommendations adopted by the CDC Director, HRSA guidelines, Bright Futures periodicity schedule, and the Uniform Screening Panel for newborns.

Women's preventive servicesGuidelines specifically issued for women are required to be covered without cost‑sharing for in‑network services as effective for plans on or after August 1, 2012.

Where to find detailsRefer to the USPSTF, ACIP/CDC, HRSA, Bright Futures, and RUSP resources and the Mass General Brigham Health Plan Preventive Grid for specific services and schedules.