CurrentSelectHealthPolicy N/A

wellness_visits_coverage_details

Defines coverage of adult annual wellness visits, well-child visits from birth through age 20, and preventive prenatal care services including associated tests and immunizations; includes member outreach methods. Does not include detailed billing codes or prior authorization rules.

Policy Summary

PayerSelectHealth

Policywellness_visits_coverage_details

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnsure adult wellness visits are billed no more frequently than one visit every 12 months per member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1/12 moAdult wellness visit frequency

birth-20Well-child covered ages

tests & immunizationsWell-child services included

Coverage Summary

This policy covers adult annual wellness visits, well-child visits from birth through age 20, and preventive prenatal care including screening for anemia and diabetes. Adults are eligible for one covered wellness visit every 12 months. Well-child visits for children and teens (younger than 21) include medical tests and immunizations. Preventive prenatal services include tests for issues that may arise during pregnancy such as anemia and diabetes. The plan conducts member outreach using mailers, brochures, and automated phone calls to inform and remind members about preventive services, vaccines, and exams.

Medical Necessity / Coverage Criteria

Adult Wellness Visits

Covered when ALL of the following are met:

ALL of the following

Member is an adult (age not explicitly defined in document but implies 21 and older).
One wellness visit provided per member every 12 months.

Well-child Visits (Children and Teens)

Covered when ALL of the following are met:

ALL of the following

Member is younger than 21 years of age (birth through age 20).
Well-child visits include medical tests and immunizations as part of preventive care.

Preventive Prenatal Care Services

Covered when ALL of the following are met:

ALL of the following

Member is pregnant.
Preventive prenatal services include tests for issues that may arise during pregnancy such as anemia and diabetes.

Provider Actions & Billing Guidance

Documentation Required

Frequency limitation for adult wellness visits

Ensure adult wellness visits are billed no more frequently than one visit every 12 months per member.

Documentation Required

Age-based eligibility for well-child visits

Provide well-child visit services and associated immunizations and tests for members from birth through age 20; verify member age on date of service.

Documentation Required

Prenatal preventive testing

Document preventive prenatal tests (e.g., anemia and diabetes screening) as part of prenatal care services.

Documentation Required

Member outreach

Plans use mailers, brochures, and automated phone calls to notify members about preventive services and upcoming vaccines/exams.

Note

Member Services contact for benefit details

Direct members/providers to Member Services for more information about adult preventive care benefits.

Background & FAQs

This policy states that wellness and preventive care visits are covered: one adult wellness visit annually; well-child visits from birth through age 20 including medical tests and immunizations; and preventive prenatal care including screening for anemia and diabetes. The plan conducts outreach to remind members of preventive services using mailers, brochures, and automated phone calls, and directs members to Member Services for more information.

Question	Answer
How often are adult wellness visits covered?	Adults qualify for one covered wellness visit every 12 months.
What ages are eligible for well-child visits?	Children from birth through age 20 (younger than 21) are eligible for well-child visits.
Does the plan provide prenatal preventive care?	Yes; preventive prenatal care services including testing for anemia and diabetes are offered.

Policy Summary

PayerSelectHealth

Policywellness_visits_coverage_details

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnsure adult wellness visits are billed no more frequently than one visit every 12 months per member.

SourceLink

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