Currentpriority healthPolicy N/A

MEDICARE ANNUAL WELLNESS VISIT / PREVENTIVE CARE VISITS

Defines Priority Health's billing, coding, limits, and member cost-sharing for Medicare Welcome to Medicare visits, Annual Wellness Visits, and supplemental preventive physical exams for Medicare members.

Policy Summary

Payerpriority health

PolicyMedicare Annual Wellness Visit / Preventive Care Visits

Policy CodePolicy N/A

Change TypeCoding frequency clarifiedadded disclaimer and related denial language

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document any required authorization and confirm medical necessity; authorization is not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Added 'Related denial language' section and included prism explanation code pf1 - Code previously billed/paid on fac claim.

G0438 or G0439 was updated to 'once in a 12-month period' from 'once in a calendar year'.

Once per lifetimeLimit for Welcome to Medicare (IPPE)

Once in 12 monthsLimit for G0438/G0439 (AWV)

$0Member cost for supplemental exam same day as AWV

G0402, G0438, G0439, 99381-99397Common codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Coverage criteria for Medicare preventive visits

Priority Health covers Medicare preventive visits with specified limits, coding, modifier usage, and denial language considerations.

Preventive services by in-network providers are covered with no member cost-sharing; nonpreventive services performed in conjunction may require copayment, deductible, or coinsurance.

Welcome to Medicare (G0402) is limited to once per lifetime and must be used within 12 months of the Medicare effective date; Priority Health does not reimburse G0402 when performed on the same date as other preventive medicine exams and services.

Annual Wellness Visit (AWV) limits: G0438 (initial) and G0439 (subsequent) are limited; policy specifies G0438 or G0439 once in a 12-month period.

Supplemental 'Free to talk' preventive physical exam is a Priority Health Medicare benefit; it may be performed in conjunction with an AWV and, when done the same day, the member will pay $0 for both visits. Any labs or tests ordered as a result follow normal copay structure.

Preventive medicine CPT codes (covered when applicable): 99381-99387 (new patient) and 99391-99397 (established patient). Verify the member has not already received an AWV or preventive physical exam to avoid duplicate, non-medically necessary services.

Modifier usage: use modifier 52 to report a preventive physical exam given on the same day as an annual wellness exam.

Billing and documentation requirements: providers must follow CPT/HCPCS/revenue code reporting and document services to the highest level of specificity. Failure to document services will result in denial.

Authorization and payment integrity: authorization requirements and medical necessity requirements appropriate to procedure, diagnosis and frequency remain required; an authorization is not a guarantee of payment. Payment integrity pre- or post-claim reviews may result in claim rejection, denial, or recoupment if guidelines are not followed.

Related denial language: prism explanation code pf1 indicates code previously billed/paid on facility claim; payment integrity reviews may use this when applying denials or recoupments.

Coding and Frequency Limits

Medicare preventive visit and preventive medicine codesCPTCovered

G0402	Welcome to Medicare visit (initial visit)
G0403	EKG with Welcome to Medicare visit
G0404	EKG tracing for Welcome to Medicare visit
G0405	EKG interpretations & report for Welcome to Medicare visit
G0438	Initial annual wellness visit
G0439	Subsequent annual wellness visit
99381-99387	Preventive medicine new patient
99391-99397	Preventive medicine established patient

Notemixed

G0402_note

Priority Health does not reimburse G0402 when performed on the same date as other preventive medicine exams and services.

Frequency limits

Welcome to Medicare (G0402)Once per lifetime; must be used within 12 months of Medicare effective date.

G0438 / G0439 (Annual Wellness Visit)Once in a 12-month period (policy updated from 'calendar year' to '12-month period').

Preventive physical exam (supplemental)Once in a 12-month period per policy review guidance.

Provider Actions and Requirements

Prior Authorization

Authorization and payment not guaranteed — meet medical necessity & documentation requirements

Authorization and medical necessity requirements appropriate to the procedure, diagnosis, and frequency still apply. An authorization on file does not guarantee payment; providers must follow CPT/HCPCS/revenue code reporting and fully document services rendered to the highest level of specificity. Failure to follow billing, coding, documentation, or government program rules may result in claim rejection, denial, or recovery/recoupment.

Authorization requirements and medical necessity must be met for the service rendered.
Use industry-standard CPT, HCPCS, and revenue codes only when the service was performed and fully documented.
An authorization is not a guarantee of payment if billing, coding, or policy requirements are not followed.
Priority Health may reject/deny claims or recover payments if guidelines are not followed.

Definitions and Member Cost

Member cost-sharing for preventive services

In-network preventive servicesNo member cost-sharing for preventive services rendered by in-network providers.

Nonpreventive services during same visitMembers may owe copayment, deductible, or coinsurance for nonpreventive services performed in conjunction with a preventive visit.

Supplemental same-day preventive examWhen a 'free to talk' supplemental preventive physical exam is performed same day as AWV, member cost shown as $0 for the supplemental exam (labs/tests follow normal cost rules).

Welcome to Medicare visit / IPPE

DefinitionWelcome to Medicare visit (Initial Preventive Physical Exam, IPPE) is a one-time exam for members new to Medicare, performed in addition to annual physical exams.

Timing/use