EmblemHealth Preventive Care/Screening Services Exempt from Cost-Share

Date Issued: 4/18/2016

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The Affordable Care Act (ACA) requires non-grandfathered health plans in the individual and group markets to cover certain preventive/screening care services received from in-network providers, in full, without member cost-sharing (i.e., without co-pay, deductible and/or co-insurance). In general, eligible services include preventive/screening care services which have received an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF) or have been set forth in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), as well as immunizations recommended by the Advisory Committee on Immunization Practices (ACIP). For additional information about these guidelines and recommendation, please click on the link(s) below:

http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

http://bphc.hrsa.gov/policiesregulations/preventiveguide.html

http://www.cdc.gov/vaccines/acip/

Instructions to Providers for Coding Claims for ACA Mandated Preventive Care Services:

In order to help EmblemHealth properly identify and accurately process claims for ACA-mandated preventive/screening care services, providers are asked to follow the coding guidelines and instructions below when submitting claims for these services to the following EmblemHealth companies: Group Health Incorporated (“GHI”), Health Insurance Plan of Greater New York (“HIP”) and HIP Insurance Company of New York (“HIPIC”).

  1. Annual Preventive Care Medical Evaluation
    1. Preventive Medicine Visits should be reported with the appropriate patient age and gender specific procedure code from the 99381 through 99397 AMA CPT Code range.
    2. The associated preventive/screening ICD diagnosis code (e.g., V70.0) should be entered into the first claim diagnosis field.
  2. Preventive/Screening Colonoscopy
    1. Services provided by the in-network endoscopist, anesthesiologist and pathologist associated with an in-network preventive/screening colonoscopy are eligible for coverage without member cost-sharing.
    2. With the understanding that a preventive/screening colonoscopy may become diagnostic or therapeutic due to unforeseen findings, the AMA CPT Code that most accurately represents the procedure performed should be reported.
    3. The appropriate preventive/screening ICD diagnosis code (e.g., V76.51) should be entered into the first claim diagnosis field. 
    4. Anesthesia services should be reported with the appropriate preventive/screening ICD diagnosis code (e.g., V76.51) entered into the first claim diagnosis field. While modifier 33 may be reported along with the anesthesia CPT code, it is not used in making preventive care benefit determinations; EmblemHealth considers the procedure and diagnosis codes when determining whether preventive care benefits apply.
    5. Pathology services should be reported with the appropriate screening ICD diagnosis code (e.g., V76.51) entered into the first claim diagnosis field.
  3. All Other Preventive/Screening Services (e.g., Screening Mammography, Lipid Profile)
    1. Eligible preventive screening services should be reported with the appropriate screening ICD diagnosis code (e.g., V76.10, V70.0) and entered into the first claim diagnosis field.

    Please note that for preventive/screening services provided after September 30, 2015, the appropriate ICD-10 diagnosis code will be required on submitted claims; ICD-9 diagnosis codes will not be recognized.

    Please refer to the EmblemHealth Preventive Care/Screening Services Table.