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PAP231

Recommended Preventive Benefits


Provider Administrative Policy

Section
Claims Submission
Policy Date
July 2007
Status/Date
Revised/October 2013
Provider Type(s)
Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Recommended Preventive Benefits

Blue Cross of Idaho defines preventive services as routine healthcare screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

The Departments of Health and Human Services (HHS) issued interim final regulations requiring new plans and insurers to cover certain preventive services without any cost-sharing for the member when delivered by contracting or participating (in-network) providers. The interim final regulations do not apply to grandfathered plans. Grandfathered plans are exempt from certain provisions of this law.

Prior to a plan or policy renewal, or if a self-insured plan remains grandfathered, the current wellness/preventive member benefits apply.

Upon plan or policy renewal: Members can receive the recommended preventive services without member cost-sharing when delivered by an in-network provider. Both the Patient Protection and Affordable Care Act's (PPACA) general requirement and the new rules link to three government agencies that publish recommendations and guidelines for preventive care and require plans to provide in-network coverage for:

  • Evidence-based items or services rated A or B in the United States Preventive Services Task Force recommendations
  • Immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) and Prevention
  • Women's Preventive Services:  Required Health Plan Coverage Guidelines: http//www.hrsa.gov/womens guidelines/

Preventive care and screenings for women, infants, children, and adolescents set forth in comprehensive guidelines supported by the Health Resources and Services Administration.

The following website HealthCare.gov offers more information regarding recommended preventive services and immunizations.

Summary of Preventive Care Benefit
The following is a high-level summary of the services covered under the Preventive Care Benefit:

All members:  Yearly Preventive Medicine visits (Wellness Visits); all routine immunizations recommended by the ACIP of the CDC.

All members at an appropriate age and/or risk status: Screening for: colorectal cancer; elevated cholesterol and lipids; certain sexually transmitted diseases; HIV; depression; high blood pressure; diabetes. Screening and counseling for alcohol or substance abuse in a primary care setting; tobacco use; obesity; diet and nutrition.

Women's Health: Screening mammography; cervical cancer screening including cytology; genetic counseling and evaluation for BRCA breast and ovarian cancer genetic testing; counseling for chemoprevention for women at high risk for breast cancer; counseling and screening for gonorrhea, Chlamydia, syphilis and HPV; osteoporosis screening (age 60 or older).

The Expanded Women's Preventive Services provides coverage for:

  • Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt "religious employers."
  • Breastfeeding support, supplies and counseling are covered when provided by a covered Provider under the Member's plan.

If maternity benefits are available under the member's plan, screening pregnant women diabetes, anemia and iron deficiency, bacteriuria; hepatitis B virus, Rh incompatibility; instructions to promote and aid with breast feeding.

Men's Health: Screening for prostate cancer for men age 40 and older; screening for abdominal aortic aneurysm in men 65 - 75 years old.

Pediatrics: Screening newborns for hearing problems, thyroid disease, phenylketonuria, sickle cell anemia, and standard metabolic screening panel for inherited enzyme deficiency diseases.

Children: Counseling regarding fluoride for prevention of dental cavities; screening for major depressive disorders; vision; lead; tuberculosis; developmental/autism; counseling for obesity.

Limitations:

  1. Another portion of the medical benefit plan may cover services not covered under the preventive care benefit.
  2. Preventive care benefits do not cover the cost of drugs, medications, vitamins or supplements recommended or prescribed for preventive measures. Examples include, but are not limited to:
    • Aspirin for any indication, including but not limited to, aspirin for prevention of cardiovascular disease.
    • Chemoprevention for any indication, including but not limited to, chemoprevention for breast cancer. 
  3. Supplements, including but not limited to: oral fluoride supplementation, and folic acid supplementation.
  4. Blue Cross of Idaho will identify services by the diagnosis code.
  5. Modifier 33 Preventive Service; When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used. 

    While modifier 33 may be reported, Blue Cross of Idaho is not currently recognizing it when determining whether preventive care benefits would apply.
     

Preventive Diagnosis Codes

V10.05 Personal HX neoplasm intestine

V10.06 Personal HX neoplasm rectum

V10.3 Personal HX neoplasm breast

V12.72 Personal HX colonic polyps

V15.82 Personal HX tobacco use

V15.86 Suspected exposure to lead

V16.0 Family HX neoplasm GI tract

V16.3 Family HX neoplasm breast

V16.41 Family HX neoplasm ovary

V16.42 Family HX neoplasm prostate

V18.51 Family HX colonic polyps

V20.0 to V21.9 Health Supervision Child

V22.0 to V22.2 Pregnancy (for Maternity preventive services only)

 

V23.0 to V23.9 High Risk Pregnancy (for Maternity preventive services only)

V25.01 to V25.09 Contraceptive excluding V25.03 and V25.8

V231 to V26.66 Testing for genetic disease

V65.44 to V65.45 HIV and/or other sexually transmitted disease counseling

V69.2 High risk sexual behavior

V70.0 Routine Medical Exam

V70.3 Medical Exam administrative

V72.31 Gynecological Examination

V72.62 Routine labs

V73.3 Rubella screening

V73.81 HPV screening

V73.88 Chlamydial screening

V73.89 Screening for other viral disease

V73.98 Special Screening examination for  unspecified chlamydial disease

V74.1 Screening for TB

V74.5 Screening for venereal disease

V76.11 Screening mammogram high risk

V76.12 Screening mammogram

V76.2 Screening neoplasm cervix

V76.41 Screening neoplasm rectum

V76.44 Screening neoplasm prostate

V76.47 Screening neoplasm vagina

V76.50 Screening neoplasm intestine

V76.51 Screening neoplasm colon

 

V76.52 Screening neoplasm small intestine

V77.0 Screening thyroid

V77.1 Screening diabetes

V77.3 Screening PKU

V77.8 Screening obesity

V77.91 Screening lipoid disorders

V79.0 Screening depression

V79.1 Screening alcoholism

V81.1 Screening HT

V81.2 Screening other CV conditions

V82.81 Screening osteoporosis

305.1 Tobacco use disorder

         

 


Policy History

Date Action Reason
April 2012 Revised Added Language for HPV coverage for males.
April 2011 Revised Added new ICD9 codes and summary of benefits for 2011
February 2011 Revised Policy rewritten
July 2009 Revised Code descriptions added
March 2009 Revised New wellness benefit codes added

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