Date Issued: 1/23/2019
Last Revised: 1/1/2021
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 copay, deductible and/or coinsurance). 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) and the American Academy of Pediatrics “Bright Futures” guidelines. For additional information about these guidelines and recommendation, please click on the link(s) below:
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 EmblemHealth.
I) Annual Preventive Care Medical Evaluation
A. Preventive Medicine Visits should be reported with the appropriate patient age and gender specific procedure code from the 99381 through 99397 AMA CPT Coderange.
B. The associated preventive/screening ICD-10 diagnosis code (e.g., Z00.00, Z00.01) should be entered into the first claim diagnosisfield.
II) Preventive/Screening Colonoscopy
A. Services provided by the in-network endoscopist, anesthesiologist and pathologist associated with an in-network preventive/screening colonoscopy are eligible for coverage without membercost-sharing.
B. 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.
C. The appropriate preventive/screening ICD-10 diagnosis code (e.g., Z12.11) should be entered into the first claim diagnosisfield.
D. Anesthesia services should be reported with any specific findings entered into the first claim diagnosis field. The second claim diagnosis code should be reported with the appropriate preventive/screening ICD diagnosis code (e.g., Z12.11). CPT code 00812 MUST be used if the screening colonoscopy becomes a diagnostic colonoscopy and/or if the screening colonoscopy is stopped due to poor preparation and a sigmoidoscopy is done. 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. Pathology services should be reported with the appropriate screening ICD diagnosis code (e.g., Z12.11) entered into the first claim diagnosisfield.
III) All Other Preventive/Screening Services (e.g., Screening Mammography, LipidProfile)
A. Eligible preventive screening services should be reported with the appropriate screening ICD diagnosis code(e.g., Z12.39, Z00.00, and Z00.01) and entered into the first claim diagnosisfield.
EmblemHealth Preventive Care/Screening Services Table:
For more information, view the EmblemHealth Preventive Care/Screening Services table.