Essential Preventive Health Services for Adults and ...



Essential Benefits Chart for Preventive Health Services

The following information pertains to non-grandfathered plans and any grandfathered plans who have elected the 9/23/2010 regulation regarding prevent services. Issuers are required to provide coverage without cost sharing consistent with these guidelines in the first plan year that begins on or after the effective date provided in the chart. This list is not all-inclusive; additional procedure and/or diagnosis codes could be loaded to pay at 100% based on plan language. The benefit applies to revenue codes when services are billed by a facility/hospital. Services may vary by plan/state. When a service does not mention a frequency, there is no limit; however, it is subject to medical necessity.

The columns for Mandated Services, Requirements and Effective Dates were approved by the CoreSource and Trustmark Compliance team. The CS (CoreSource) Procedure provided under each requirement was added by Operations Training and representatives from Plan Building from each library to provide information as to how the requirement is handled within the claim system. The columns including the Diagnosis Code(s) and Procedure Code(s) were determined by the internal Health Care Reform committee and reviewed by Trustmark’s Medical Director. These codes were offered as a tool to help identify the services directly related to the requirement but are not an all-inclusive list, nor do they include additional codes that may be loaded to support the related CS Procedure or the plan loading template for routine services.

Note: Per clarification from the Departments, a plan may not limit sex-specific recommended preventive services based on an individual’s sex assigned at birth, gender identity or recorded gender. The medical appropriateness of a preventive service to an individual is determined by the individual’s physician.

This chart is intended for internal use only and should not be copied or distributed outside of the organization.

Women’s Preventive Services

The services listed below are covered in full when received from a provider within the plan’s network.

Note: Per clarification from the Departments, coverage of Well Woman Preventive Care must also be extended to dependent children, to include a full range of recommended preventive services applicable to them (e.g. Age appropriate and developmentally appropriate)

|Mandated Service |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|W = Women only | | | | |

|Well Woman Visits W |Requirement: |08/01/2012 | |99381, 99382, 99383, 99384,|

| |Includes an annual well woman preventive care visit|12/20/2017 | |99385, 99386, 99387, |

| |for adult women to obtain the recommended | | |99391, 99392, 99393, 99394,|

| |preventive services, and additional visits if women| | |99395, 99396, 99397, |

| |and their providers determine they are necessary | | |G0402, G0438, G0439, G0445,|

| |Includes at least one preventive care visit per | | |S0610, S0612, S0613, |

| |year beginning in adolescence and continuing across| | | |

| |the lifespan to ensure the recommended preventive | | | |

| |services, including prenatal care, are obtained. | | | |

| |CS Procedure: Pay at 100% with any routine | | | |

| |diagnosis regardless of exam procedure code and | | | |

| |without age limit | | | |

|Breastfeeding Support, Supplies and |Requirement: |09/01/2009 |ICD9 – 676.8, V24.1 |98960, 99241, 99242, 99243,|

|Counseling W |Comprehensive lactation support and counseling, by |12/20/2017 |ICD10 – O92.79, Z39.1 |99244, 99245, |

|Breastfeeding Services and Supplies W |a trained provider during pregnancy and/or in the | | |99341, 99342, 99343, 99344,|

| |postpartum period, and costs for purchasing and | | |99345, 99346, 99347, 99348,|

| |renting breastfeeding equipment. | | |99349, 99350, |

| |Comprehensive lactation support services (including| | |99401, 99402, 99403, 99404 |

| |counseling, education and breastfeeding equipment | | |A4281, A4282, A4283, A4284,|

| |and supplies) during the antenatal, perinatal and | | |A4285, A4286, |

| |the postpartum period to ensure the successful | | |E0602, E0603, E0604, |

| |initiation and maintenance of breastfeeding. | | |S9443 |

| |OON claims for lactation counselors are to be paid | | | |

| |at 100% | | | |

| |Frequency is in conjunction with each birth. | | | |

| |CS Procedure: This benefit is loaded to allow | | | |

| |without frequency restrictions. | | | |

| |Lactation counseling is paid as in-network. New | | | |

| |clients coded to pay in network whether the | | | |

| |provider is in or out of network. Existing clients| | | |

| |will be handled on appeal and plan coding will be | | | |

| |updated as the group renews. | | | |

|Breast Cancer (Mammography) W |Requirement: |09/01/2005 |ICD9 – V76.1 |77052, 77055, 77056, 77057 |

|Breast Cancer Screening for Average-Risk |Every one or two years for ages 40 and older |07/01/2017 |ICD10 – Z12.31, Z12.39 |G0202, G0204, G0206 |

|Women W |Administrative guideline to allow 3D mammograms |12/20/2017 | | |

| |Mammography screening no earlier than age 40 and no| | |Effective 07/01/2017: |

| |later than age 50 for average-risk women. | | |77061, 77062, 77063, G0279 |

| |Screening mammography should occur one to two times| | | |

| |annually. Screening should continue through at | | | |

| |least age 74 (but not discontinue based on age | | | |

| |alone). | | | |

| |Women at increased risk should also undergo | | | |

| |periodic mammography screening. However, | | | |

| |recommendations for additional services are beyond | | | |

| |the scope of this recommendation. | | | |

| |CS Procedure: | | | |

| |Allow regardless of frequency for age 40 and above | | | |

| |KC & LR – not limited to age 40 & above unless | | | |

| |limited in plan doc limits it | | | |

|Breast Cancer – High Risk (Cancer |Requirement: Women beginning at age 40 at high |09/23/2010 | |99401, 99402, 99403, 99404 |

|Prevention Counseling) W |risk for breast cancer | | | |

| |CS Procedure: follow requirement regardless of age | | | |

|Breast Cancer – High Risk (Medications) W |Requirement: Tamoxifen or Raloxifene when |09/21/2014 | | |

| |prescribed by physician for women at high risk for | | | |

| |breast cancer | | | |

|Cervical Cancer (PAP Smear and HPV |Requirement: Cervical cancer screening for |03/01/2013 |ICD9 – V72.3, V76.2 |88141, 88142, 88143, 88144,|

|Testing) W |average-risk women ages 21-65. | |ICD10 – Z01.411, Z01.419, |88145, 88146, 88147, 88148,|

|a.k.a. Screening for Cervical Cancer |Ages 21-29, cervical cancer screening using Pap | |Z12.4 |88149, 88150, 88151, 88152,|

| |test every 3 years. | | |88153, 88154, 88155, |

| |(co-testing with Pap and HPV is not recommended for| | |88164, 88165, 88166, 88167,|

| |women under 30 years) | | |88174, 88175 |

| |Ages 30-65, Pap test and HPV testing every 5 years | | |Q0091 |

| |or Pap test alone every 3 years. | | | |

| |Women who are at average risk should not be | | | |

| |screened more than once every 3 years. | | | |

| |CS Procedure: Allow regardless of age or | | | |

| |frequency, unless limited in the plan documentation| | | |

|Contraceptive Methods (FDA-Approved) as |Requirement: |08/01/2012 |ICD9 – V25.01-V25.04, V25.09, |00952, 00851, 11976, |

|Prescribed and Contraceptive Counseling W|Women will have access to all FDA-approved |1a. 12/20/2017 |V25.11, V25.13, V25.2, |11980, 11981, 11982, 11983,|

|1a. Contraception W |contraceptive methods, sterilization procedures |01/01/2014 |V25.41-V25.43, V25.49, V25.5, |57170, 58300, 58301, 58340,|

| |(including pre-operative services) and patient | |V25.8, V25.9, V26.51 |58565, 58600, 58605, 58611,|

| |education and counseling. (This includes | |ICD10 – Z30.02, Z30.09, |58615, 58670, 58671, 58700,|

| |“Emergency Contraceptives”, “Abortifacient” drugs, | |Z30.011, Z30.012, Z30.014, |74740, 96372, |

| |and insertion and removal of IUDs.) | |Z30.018, Z30.2, Z30.40, |A4261, A4264, A4266, A4268,|

| |Frequency is as prescribed. | |Z30.41, Z30.430, Z30.431, |A4269, |

| |1a. Adolescent and adult women will have access to | |Z30.433, Z30.49, Z30.8, Z30.9,|J1050, J1051, J1056, J1885,|

| |all FDA-approved contraceptive methods, effective | |Z98.51 |J3490, J7297, J7298, J7300,|

| |family-planning practices and sterilization | | |J7302, J7303, J7304, |

| |procedures available as part of contraceptive care | | |J7306, J7307, Q9984, S4981,|

| |to prevent unintended pregnancy and improve birth | | |S4989, S4993, |

| |outcomes. Contraceptive care initiation of | | |also any office visit code |

| |contraceptive use and follow-up care (e.g., | | |with these diagnosis codes |

| |management and evaluation, as well as changes to | | | |

| |and removal/discontinuation of contraceptive | | | |

| |method). | | | |

| |OTC contraception is covered if FDA approved and | | | |

| |prescribed for a woman by her provider. | | | |

| |Note: this does not include male condoms | | | |

| |Refer to the list on the right for a full range of | | | |

| |FDA identified contraceptive methods for women and | | | |

| |details on patient liability. This list can also | | | |

| |be located in the FDA Identified Contraceptive | | | |

| |Methods entry under Healthcare Reform and then | | | |

| |Preventive Health Services in the Compliance | | | |

| |section of the BRS. | | | |

| |Note: The above does not apply to women who are | | | |

| |participants or beneficiaries in group health plans| | | |

| |sponsored by religious employers. | | | |

| |CS Procedure: This benefit is loaded to pay at | | | |

| |100% in-network | | | |

| | |FDA Identified Contraceptive Methods: |

| | |The full range of contraceptive methods for women currently identified by the FDA|

| | |include: |

| | |Cervical Caps |

| | |Female Condoms |

| | |Diaphragms |

| | |Emergency Contraception (Levonorgestrel and Ulipristal Acetate) |

| | |Copper Intrauterine Devices |

| | |Intrauterine Devices With Progestin (All Durations and Doses) |

| | |Oral Contraceptives (“Combined” Pills) |

| | |Oral Contraceptives (Progestin Only) |

| | |Oral Contraceptives (Extended or Continuous Use) |

| | |The Contraceptive Patch |

| | |Vaginal Contraceptive Rings |

| | |Implantable Rods |

| | |Contraceptive Sponges |

| | |Shot or Injection |

| | |Spermicides |

| | |Sterilization Surgery for Women |

| | |Surgical Sterilization Via Implant for Women |

| | |Additional methods as identified by the FDA |

| | |Additionally, instruction in fertility awareness-based methods, including the |

| | |lactation amenorrhea method, although less effective, should be provided for |

| | |women desiring an alternative method. |

| | |Note: The above do not apply to women who are participants or beneficiaries in |

| | |group health plans sponsored by religious employers. |

|Domestic Violence and Counseling W |Requirement: |01/01/2014 |ICD9 – V15.41, V15.42, V15.49,|96150, 98960, |

|Screening and Counseling for Interpersonal|Screening and counseling for interpersonal and |12/20/2017 |V61.11, V61.12, V61.21, |99401, 99402, 99403, 99404,|

|and Domestic Violence W |domestic violence for women of childbearing age | |V62.81, |99420, |

| |Screening of adolescents and women for | |995.81-995.83 | |

| |interpersonal and domestic violence at least | |ICD10 – T74.11XA, T74.21XA, | |

| |annually and, when needed, providing or referring | |T74.31XA, T76.11XA, T76.21XA, | |

| |for initial intervention services. | |T76.31XA | |

| |CS Procedure: This benefit is loaded to allow | |Z65.8, Z69.010, Z69.11, | |

| |without age restriction | |Z69.12, Z91.410, Z91.411, | |

| | | |Z91.412, Z91.49 | |

|Screening for Gestational Diabetes |Requirement: |01/01/2015 |ICD9 – V77.1 |82947, 82948, 82950, 82951,|

|Mellitus W |Screening for women after 24 weeks pregnant |(administratively as |ICD10 – Z13.1 |82952, 83036 |

| |Screening for women after 24 weeks of gestation |of 08/01/12) | | |

| |(preferably between 24 and 28 weeks of gestation) |12/20/2017 | | |

| |or for those at high risk of developing gestational| | | |

| |diabetes, screening before 24 weeks of gestation – | | | |

| |ideally at the first prenatal visit, based on | | | |

| |current clinical best practices | | | |

| |CS Procedure: follow requirement without holding | | | |

| |to confirm number of weeks | | | |

|Human Immunodeficiency Virus (HIV) |Requirement: |01/01/2012 |ICD9 – V08 | |

|Screening and Counseling W |Annual screening and counseling on HIV infection |12/20/2017 |ICD10 – Z21 | |

|Screening for Human Immunodeficiency Virus|Annual screening throughout the lifespan on | | | |

|(HIV) Infection W |HIV-prevention education and risk assessment in | | | |

| |adolescents and women. Additional screening | | | |

| |annually or more often may be appropriate for | | | |

| |adolescents and women with an increased risk of HIV| | | |

| |infection | | | |

| |Screening for HIV is recommended for all pregnant | | | |

| |women upon initiation of prenatal care with | | | |

| |retesting during pregnancy based on risk factors. | | | |

| |CS Procedure: Allow regardless of age or gender | | | |

|Human Papilloma Virus (HPV) DNA Testing |Requirement: |01/01/2012 |ICD9 – V70.0, V72.31, V73.81, |87620, 87621, 87622, 87623,|

|for Women Age 30 and Older W |Women who are 30 or older will have access to |03/01/2013 |V76.2 |87624, 87625 |

| |annual screening | |ICD10 – Z00.00, Z01.411, | |

| |Refer to Cervical Cancer in this document | |Z01.419, Z11.51, Z12.4 | |

| |CS Procedure: follow requirement regardless of age | | | |

| |or frequency | | | |

|Preeclampsia Prevention W |Requirement: |09/01/2014 | | |

| |Low-dose aspirin (81 mg/d) as preventive medication|04/01/2018 | | |

| |after 12 weeks of gestation in women who are at | | | |

| |high risk for preeclampsia | | | |

| |Preeclampsia screening for preeclampsia in pregnant| | | |

| |women with blood pressure measurements throughout | | | |

| |pregnancy | | | |

|Prenatal Care W |Requirement: Prenatal care must be covered at 100%|01/01/2014 | |See Screening for Pregnant |

| |whether group has a maternity coverage option or | | |Women section |

| |not | | | |

| |(see also Well Woman Visits in this document) | | | |

|Sexually Transmitted Infections (STI) |Requirement: |01/01/2012 |ICD9 – V65.44, V65.45 |G0445 |

|Counseling W |Counseling on STI’s for those who are increased |12/20/2017 |ICD10 – Z71.7, Z71.89 | |

| |risk for sexually transmitted infections | | | |

| |Behavioral counseling for sexually active | | | |

| |adolescents and adult women at an increased risk | | | |

| |for sexually transmitted infections STIs. | | | |

| |For adolescents and women not identified as high | | | |

| |risk, counseling to reduce the risk of STIs should | | | |

| |be considered, as determined by clinical judgement.| | | |

Essential Preventive Health Services for Adults

The routine exams, immunizations & screenings for adults age 18 & older listed below are covered in full when received from a provider in the plan’s network.

|Wellness Exam or Health |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|Screening | | | | |

|M=Men only, W=Women only | | | | |

|Routine Physical Exams and |Requirement: When billed with and related to preventive |09/23/2010 |ICD9 – V70.0 |99385, 99386, |

|Check-ups |services | |ICD10 – Z00.00 |99387, 99388, 99389, 99390, 99391, |

| |CS Procedure: Pay at 100% with any routine diagnosis | | |99392, 99393, 99394, 99395, 99396, |

| |regardless of exam procedure code and without age limit | | |99397 |

|Abdominal Aortic Aneurysm M|Requirement: Ultrasound screening for all men ages 65-75 who |02/01/2006 |ICD9 – V81.2 |76770, 76705, 76775 |

| |have ever smoked, one time in lifetime | |ICD10 – Z13.6 | |

| |CS Procedure: follow requirement regardless of age, gender or | | | |

| |frequency | | | |

|Alcohol Misuse Screening |Requirement: Counseling sessions for patients who meet |05/01/2014 |ICD9 – 305.0, V79.1 |90804, 96150, 98960, |

|and Counseling |criteria for alcohol misuse. Includes coverage for persons |(administratively as|ICD10 – F10.10, F10.120,|99401, 99402, 99420, |

| |engaged in risky or hazardous drinking with limited behavioral |of 09/23/10) |F10.129, Z13.89 |99384, 99385, 99386, 99387, |

| |counseling to reduce misuse. | | |99394, 99395, 99396, 99397, |

| |CS Procedure: Follow requirement as of 09/23/2010. | | |G0442, G0444 |

| | | | |H0001, H0049 |

|Cardiovascular Disease |Requirement: |03/01/2009 | |99401, 99402, 99403, 99404 |

|(CVD) |General Counseling and Counseling on the use of aspirin for men|01/01/2014 | | |

| |ages 45-79 and women ages 55-79 | | | |

| |Effective 01/01/2014, over the counter aspirin is covered for | | | |

| |individuals at risk of cardiovascular disease when prescribed | | | |

| |by a doctor | | | |

| |CS Procedure: Allow without age restriction. Pay regardless | | | |

| |of prescription, even though RX is required. | | | |

| |Customer Service: Advise the caller a prescription is | | | |

| |required. | | | |

|Chlamydia Infection |Requirement: For all sexually active non-pregnant women up to |06/01/2005 |ICD9 – V73.88, V73.98 |87110, 87270, 87320, |

|Screening W |age 24 and older non-pregnant women who are increased risk | |ICD10 – Z11.8 |87490, 87491, 87492, 87810 |

| |CS Procedure: Allow regardless of age or gender | | | |

|Cholesterol Screening |Requirement: Ages 20-35 for men and 20-45 for women at |06/01/2009 |ICD9 – V77.91 |82465, 83718, 83719 |

| |increased risk of cardiovascular disease; otherwise, beginning | |ICD10 – Z13.220 | |

| |at age 35 for men and age 45 for women | | | |

| |CS Procedure: Allow without age or gender restriction | | | |

|Colorectal Cancer Screening|Requirement: Follow American Cancer Society guidelines. |10/01/2009 |ICD9 – V76.51 |45330, 45331, 45332, 45333, 45334, |

| |Beginning at age 50 and continuing to age 75, w/o specific risk| |ICD10 – Z12.11 |45335, 45336, 45337, 45338, 45339, |

| |factors: | | |45340, 45341, 45342, 45343, 45344, |

| |Every year – fecal occult blood test or fecal immunochemical | | |45345, |

| |test | | |45355, 45356, 45357, 45358, 45359, |

| |Every 5 years – flexible sigmoidoscopy, double-contract barium | | |45360, 45361, 45362, 45363, 45364, |

| |enema or CT colonography | | |45365, 45366, 45367, 45368, 45369, |

| |Every 10 years – Colonoscopy | | |45370, 45371, 45372, 45373, 45374, |

| |(includes pre-procedure consultation, bowel preparation kit and| | |45375, 45376, 45377, 45378, 45379, |

| |pathology exam, anesthesia services performed in connection | | |45380, 45381, 45382, 45383, 45384, |

| |with the colonoscopy and biopsy/pathology related to incidental| | |45385, 45386, 45387, 45388, 45389, |

| |polyp removal regardless if routine or not) | | |45390, 45391, 45392, |

| |Screening should begin earlier and more frequently for patients| | |74261, 74262, 74263, |

| |with colorectal cancer risk factors. | | |82270, 82274, 88305, 88305-26 |

| |CS Procedure: | | |G0328, |

| |all covered without frequency limit | | |G0104, G0105,G0106, G0107, |

| |KC, Detroit, LR – allow without any age restriction unless | | |G0120, G0121, G0122 |

| |limited in plan doc | | | |

|Depression Screening |Requirement: As medically necessary |12/01/2010 |ICD9 – V79.0 |99420 |

| |CS Procedure: Allow without review of medical necessity | |ICD10 – Z13.89 | |

|Diabetes (type 2) Screening|Requirement: For individuals with high blood pressure |06/01/2009 |ICD9 – V77.1 |82947, 82948, 82949, 82950, 82951, |

| |CS Procedure: allow without restriction or review of blood | |ICD10 – Z13.1 |82952, |

| |pressure | | |82962, 83037, 99385, 99386, 99395, |

| | | | |99396 |

|Falls Prevention |Requirement: Exercise or physical therapy and Vitamin D |05/01/2013 |ICD9 – V15.8, V15.88 | |

| |supplement for those 65 years and older living in a community | |ICD10 – Z91.81 | |

| |dwelling | | | |

| |CS Procedure: Hold dx V15.88 for review. V15.8 reviewed on | | | |

| |appeal. Pay at 100% with claim type. | | | |

|Folic Acid Supplementation |Requirement: Coverage for daily supplement for women planning |05/01/2010 | |J3490, |

|W |or capable of pregnancy | | |99401, 99402, 99403, 99404 |

| |CS Procedure: Hold claims with code J3490 | | | |

| |Note: Includes prenatal vitamins because they contain folic | | | |

| |acid | | | |

|Genetic Testing (referral |Requirement: |12/01/2014 |ICD9 – V16.3, V82.7 |81211, 81212, 81213, 81214, 81215, |

|for BRCA counseling and |For women with family history of an increased risk for |(administratively as|ICD10 – Z13.71, Z13.79, |81216, 81217, |

|evaluation) W |deleterious mutations in BRCA1 or BRCA2 genes and for women who|of 09/23/10) |Z80.3 |99401, 99402, 99403, 99404 |

| |have had a prior non-BRCA related breast or ovarian cancer |(administratively as| | |

| |diagnosis, even if currently asymptomatic and cancer-free |of 02/20/13) | | |

| |Including BRCA testing if determined appropriate by physician | | | |

| |CS Procedure: System allows diagnosis and procedure | | | |

| |combination of counseling and testing without review | | | |

|Gonorrhea Infection |Requirement: |05/01/2006 |ICD9 – V74.5, V75.9 |87590, 87591, 87592, |

|Screening W |Women at increased risk for infection |09/01/2015 |ICD10 – Z11.3, Z11.9 |87850 |

| |Sexually active women age 24 years and younger and in older | | | |

| |women at increased risk for infection | | | |

| |CS Procedure: Allow regardless of age or gender and without | | | |

| |review | | | |

|Healthy Eating Assessment |Requirement: |01/01/2004 |ICD9 – V65.3, V65.4 |97802, 97803, 97804, |

|and Dietary Counseling |Intensive behavioral dietary counseling for adult patients with|08/01/2015 |ICD10 – Z71.3, Z71.89, |99201, 99202, 99203, 99204, 99205, |

|Healthy Diet and Physical |hyperlipidemia and other known risk factors for CVD and diet | |Z71.9 |99211, 99212, 99213, 99214, 99215 |

|Activity Counseling Eating |related chronic disease by primary health care provider, or by | | | |

|Assessment and Dietary |referral to other specialists, such as nutritionists or | | | |

|Counseling |dietitians | | | |

|Side Note: an assessment is|Intensive behavioral counseling interventions to promote a | | | |

|estimating the likelihood |healthful diet and physical activity for CVD prevention in | | | |

|of adverse effects |overweight or obese adults with additional cardiovascular | | | |

| |disease (CVD) risk factors | | | |

| |CS Procedure: Allow without review | | | |

|Hepatitis B Infection |Requirement: Non-pregnant adults in high risk of infection |05/01/2015 | | |

|Screening | | | | |

|Hepatitis C Infection |Requirement: |06/01/2014 | | |

|Screening |One time screening for adults with high risk of infection | | | |

| |One-time screening for adults born between 1945 and 1965 | | | |

|High Blood Pressure |Requirement: Adults age 18 and older |12/01/2008 |ICD9 – V81.1 |99201, 99202, 99203, 99204, |

|Screening |CS Procedure: Allow without age limitation | |ICD10 – Z13.6 |99205, 99211, 99212, 99213, 99214, |

| | | | |99215 |

|HIV Infection (Human |Requirement: Adults at increased risk |01/01/2014 |ICD9 – V08 |86689, |

|Immunodeficiency Virus) |CS Procedure: Allow without review |(administratively as|ICD10 – Z21 |86701, 86702, 86703, |

| | |of 09/23/10) | |87390, |

| | | | |87534, 87535, 87536 |

| | | | |S3645 |

|Lung Cancer Screening |Requirement: Annual screening with low dose CT for adults age |12/01/2014 |ICD10 – |G0296, G0297, S8032 |

| |55-80 that have a 30 pack-year smoking history who currently | |F17.210-F17.219, | |

| |smoke or have quit within the last 15 years. Screening should | |F17.290-F17.299, Z12.2, | |

| |discontinue once the person has not smoked for 15 years or | |Z72.0, Z87.891 | |

| |develops a health problem that substantially limits life | | | |

| |expectancy or the ability or willingness to have curative lung | | | |

| |surgery. | | | |

|Obesity Screening and |Requirement: Screening for all adults. For adults with a BMI |01/01/2013 |ICD9 – 278.0, 278.00, |97802, 97803, 97804, |

|Counseling for Weight Loss |of 30 or above, referral for counseling | |278.01, 278.02, 278.03, |98960, |

| |The recommendation specifies that intensive, multicomponent | |V77.8 |99401, 99402, 99403, 99404, |

| |behavioral interventions include, for example, the following: | |ICD10 – E66.01, E66.3, |99411, 99412, 99420 |

| |Group and individual sessions of high intensity (12 to 26 | |E66.2, E66.9, Z13.2, | |

| |sessions in a year), | |Z68.3-Z68.45 | |

| |Behavioral management activities, such as weight-loss goals, | | | |

| |Improving diet or nutrition and increasing physical activity, | | | |

| |Addressing barriers to change, | | | |

| |Self-monitoring, and | | | |

| |Strategizing how to maintain lifestyle changes. | | | |

| |CS Procedure: Allow screening. Counseling of age 18 and older| | | |

| |requires review of BMI. Refer to the Obesity entry in the BRS | | | |

| |for additional processing information. | | | |

|Osteoporosis Screening |Requirement: Routine screening for osteoporosis for women age |01/01/2013 |ICD9 – V82.81 |77078, 77079, 77080, |

|(Bone Density Screening) W|65 and older. For younger women whose risk of fracture is | |ICD10 – Z13.820 |99420 |

| |equal to a 65 year old woman | | | |

| |CS Procedure: ECM currently pays for procedure without age | | | |

| |limit or gender specific. | | | |

|Prostate Screening (PSA) M |Requirement: No requirement |09/23/2010 | |84152, 84153, 84154 |

| |CS Procedure: This is a grade “D” recommendation. Coverage at| | | |

| |the client’s discretion for both grandfathered and | | | |

| |non-grandfathered. NPD has language to accommodate | | | |

|Sexually Transmitted |Requirement: |10/01/2009 |ICD9 – V65.45 |99401, 99402, 99403, 99404 |

|Infection (STI) Counseling |High Intensity behavioral counseling to prevent STI’s |09/01/2015 |ICD10 – Z71.89 | |

| |High intensity behavioral counseling for adults at increased | | | |

| |risk for STI’s | | | |

| |CS Procedure: Allow regardless of gender and without review | | | |

|Statin Preventive |Requirement: |11/01/2017 | |Probably billed through PBM or could |

|Medication |Adults ages 40-75 years with no history of CVD, | | |be dispensed in the pharmacy or |

| |1 or more CVD risk factors, | | |physician’s office |

| |A calculated 10-year CVD event risk of 10% or greater | | | |

|Syphilis Infection |Requirement: For all pregnant women and persons at increased |07/01/2005 |ICD9 – V74.5 |86592, 86593, 86781, |

|Screening |risk (no time or age limits) | |ICD10 – Z11.3 |87164, 87166, 87285 |

| |CS Procedure: Allow regardless of gender and without review | | | |

|Tobacco Use Screening and |Requirement: |04/01/2011 |ICD9 – 305.1, V15.82 |99078, 99401, 99402, 99403, 99404, |

|Interventions |Counseling about tobacco use and provide tobacco cessation |05/02/2014 |ICD10 – F17.200, Z87.891|99406, 99407 |

| |interventions | | |G0436, G0437, G9016 |

| |Note: Smoking cessation drugs are not covered under HCR. Only | | |S9075, S9453 |

| |the counseling to take the drugs is covered. | | | |

| |Counseling about tobacco use and provide tobacco cessation | | |99401, 99402, 99403, 99404, 99406, |

| |interventions. This includes, at a minimum, screening for | | |99407, G0436, G0437, G9016 |

| |tobacco use and, for those that use tobacco products, at least | | | |

| |2 tobacco use attempts per plan year. | | | |

| |Note: one cessation attempt includes 4 counseling sessions of | | | |

| |10 minutes or more and all FDA approved tobacco cessation drugs| | | |

| |(whether prescription or over-the-counter) for a 90 day | | | |

| |treatment regimen when prescribed by a health care provider. | | | |

| |No prior authorization requirements may apply. | | | |

| |CS Procedure: Allow based on procedure without review | | | |

|Tuberculosis Screening |Requirement: Asymptomatic adults at increased risk for |09/01/2017 | | |

| |infection | | | |

|Screening for Pregnant |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|Women | | | | |

|Anemia Screening |Requirement: Routine screening |05/01/2007 – | | |

|(no cost sharing terminated|CS Procedure: Allow regardless of age or gender |09/01/2016 | | |

|for plan years on or after |(no cost sharing terminated for plan years on or after |(no cost sharing | | |

|09/01/16) |09/01/16) |terminated for plan | | |

| | |years on or after | | |

| | |09/01/16) | | |

|Chlamydia Infection |Requirement: |06/01/2008 |ICD9 – V73.88- V73.98, |86631, 86632, 87491 |

|Screening |Pregnant women age 24 and younger and for older pregnant women |09/01/2015 |V74.5, V75.9 | |

| |who are at increased risk | |ICD10 – Z11.3, Z11.59, | |

| |Sexually active women age 24 and younger and for older women | |Z11.8, Z11.9 | |

| |who are at increased risk | | | |

| |CS Procedure: Allow regardless of age or gender | | | |

|Hepatitis B Infection |Requirement: At first prenatal visit, with diagnosis of |06/01/2010 |ICD9 – V02.61 |87340 |

|Screening |pregnancy | |and a pregnancy | |

| |CS Procedure: Hold claims with V02.61 diagnosis and 87340 CPT | |diagnosis | |

| |at package level to review for possible maternity regardless of| |ICD10 – Z22.51 | |

| |whether it is the first visit | |and a pregnancy | |

| | | |diagnosis | |

|HIV Infection Screening |Requirement: For all pregnant women |04/01/2014 | | |

| |CS Procedure: Allow regardless of age or gender | | | |

|Iron Deficiency Anemia |Requirement: With a diagnosis of pregnancy |09/23/2010 – |ICD9 – V78.0 |85013, 85014, 85018 |

|Screening |CS Procedure: Allow regardless of age or gender |09/01/2016 |ICD10 – Z13.0 | |

|(no cost sharing terminated|(no cost sharing terminated for plan years on or after |(no cost sharing | | |

|for plan years on or after |09/01/16) |terminated for plan | | |

|09/01/16) | |years on or after | | |

| | |09/01/16) | | |

|Prenatal Care |Requirement: Prenatal care must be covered at 100% regardless |01/01/2014 | |59425, 59426, |

| |if maternity coverage is on the plan. | | |H1000, H1001, H1002, H1003, H1004, |

| |CS Procedure: Allow the initial visit and urinalysis. | | |H1005 |

| |Subsequent prenatal visits will hold and must also be paid at | | | |

| |100%. Refer to the Prenatal Care claim procedure in the BRS | | | |

| |for additional processing information. | | | |

|Rh (antibody) |Requirement: At 12-16 weeks gestation (or at first prenatal |02/01/2005 |ICD9 – V22.0, V22.1 |86901 |

|Incompatibility Testing |visit, if later) and at 24-28 weeks gestation | |ICD10 – Z34.00, Z34.80, | |

| |CS Procedure: Allow regardless of age, gender or gestation | |Z34.90 | |

|Syphilis Testing |Requirement: For all pregnant women (no time or age limits) |05/01/2010 |ICD9 – V73.88- V73.98, |86592, 86593 |

| |CS Procedure: Allow regardless of age or gender | |V74.5, V75.9 |G0450 |

| | | |ICD10 – Z11.3, Z11.59, | |

| | | |Z11.8, Z11.9 | |

|Tetanus, Diphtheria, |Requirement: 1 dose during pregnancy, regardless of when last |06/07/2016 | | |

|Pertussis (TDaP) |dosed, then follow Adult Immunizations | | | |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Tobacco Use Screening and |Requirement: Pregnancy-tailored counseling for those who smoke| |ICD9 – 305.1, V15.82 |99401, 99402, 99403, 99404, 99406, |

|Interventions |CS Procedure: Allow based on procedure without review | |ICD10 – F17.200, Z87.891|99407, G0436, G0437, G9016 |

|Urine Culture for |Requirement: Testing at 12-16 weeks gestation. Limited to one|07/01/2009 |ICD9 – V47.4 |87081, 87086 |

|Bacteriuria |test per pregnancy | |and a pregnancy code | |

| |CS Procedure: Allow regardless of age, gender, gestation or | |ICD10 – R68.89 | |

| |frequency | |and a pregnancy code | |

|Adult immunizations |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|Haemophilus Influenza Type |Requirement: Age 19 and above when some other risk factor is |02/01/2014 | | |

|B (HIB) |present (1-3 doses) | | | |

|Hepatitis A |Requirement: For those at risk (2 doses) |09/23/2010 | |90632. 90633, 90634, 90636 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Hepatitis B |Requirement: For those at risk (3 doses) |09/23/2010 | |90731, 90740, 90746 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Herpes Zoster (Shingles) |Requirement: After age 50 (1 dose) |09/23/2010 | |90736 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Human Papillomavirus (HPV) |Requirement: Ages 18-26 (3 doses) |09/23/2010 | |90649, 90650 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Influenza (Flu) |Requirement: Annually |09/23/2010 | |90655, 90656, 90657, 90658, |

| |CS Procedure: Allow without age or frequency restrictions | | |90660, 90662 |

|Measles, Mumps, Rubella |Requirement: Ages 19-49 (1 or 2 doses), After age 50 for those|09/23/2010 | |90705, 90707, 90708, 90710 |

| |at risk (1 dose) | | | |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Meningococcal |Requirement: For those at risk (1 or more doses) |09/23/2010 | |90466, 90620, 90664, 90733, 90734 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Pneumococcal |Requirement: For those at risk (1 or 2 doses), After age 65 (1|09/23/2010 | |90669, 90732 |

| |dose) | | | |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Tetanus, Diphtheria, |Requirement: 1 dose, then every 10 years |09/23/2010 |ICD9 – V03.7, V06.1, |90700, 90701, 90702, 90703 |

|Pertussis (TDaP) |CS Procedure: Allow without age or frequency restrictions | |V06.5 | |

| | | |ICD10 – Z23 | |

|Varicella (Chickenpox) |Requirement: 2 doses |09/23/2010 | |90716 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

Essential Preventive Health Services for Children and Teens

The routine exams, immunizations and screenings for children under age 18 (unless the requirement gives an older age) listed below are covered in full when received from a provider within the plan’s network.

|Well Child Exams / Health |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|Screenings for: | | | | |

|Exams for Age 0 – 36 months |Requirement: Prenatal, Newborn, 3-5 days, 1, 2, 4, 6, 9, 12, |09/23/2010 |ICD9 – V20.3 |99381, 99382 |

| |15, 18, 24, 30, 36 months | |ICD10 – Z00.1. Z00.11, | |

| |CS Procedure: Allow without age or frequency limitations | |Z00.110, Z00.111 | |

|Exams for Age 4 – 21 Years |Requirement: Annually ages 4-21 |09/23/2010 |ICD9 – V20.2 |99383, 99384, |

| |CS Procedure: Allow without age or frequency limitations | |ICD10 – Z0012, Z00.121, |99391, 99392, 99393, 99394 |

| | | |Z00.129 | |

|Alcohol and Drug Use |Requirement: Risk assessment beginning at age 11 |09/23/2010 |ICD9 – 304, 305.0, V79.1 |90804, 96150, 98960, 99384, 99385, |

| |Side Note: an assessment is estimating the likelihood of | |ICD10 – F10.10, F10.120, |99386, 99387, |

| |adverse effects | |F10.129, F11-F19, Z13.89 |99394, 99395, 99396, 99397, |

| |CS Procedure: Allow without age limitation | | |99401, 99402, 99420 |

| | | | |G0442, G0444 |

| | | | |H0001, H0049 |

|Autism |Requirement: 18 months, 24 months |09/23/2010 | | |

| |CS Procedure: Allow procedure codes billed with diagnosis | | | |

| |V79.3 & V20.2 regardless of age | | | |

|Behavioral Problems |Requirement: Newborn, 3-5 days, 1, 2, 4, 6, 9, 12, 15, 18, |09/23/2010 |ICD10 – Z13.89, Z13.4 |90899, 96127, 96150-96155, |

| |24, 30 months, then annually ages 3-21 | | |Also any E/M code |

| |Note:  provides a Pediatric | | | |

| |Symptom Checklist to help aid providers in these required | | | |

| |services. Per the Pediatric Symptom Checklist-17 (PSC-17) is | | | |

| |a psychosocial screen designed to facilitate the recognition | | | |

| |of cognitive, emotional, and behavioral problems so that | | | |

| |appropriate interventions can be initiated as early as | | | |

| |possible. | | | |

| |CS Procedure: Allow procedure codes billed with diagnosis | | | |

| |V79.2, V79.8 & V79.9 regardless of age or frequency | | | |

|Cervical Abnormalities (PAP |Requirement: Risk assessment beginning at age 11 |09/23/2010 |ICD9 – V76.2, V72.3 |88141, 88142, 88143, 88144, 88145, |

|Smear and HPV Testing) |Side Note: an assessment is estimating the likelihood of | |ICD10 – Z01.411, Z01.419, |88146, 88147, 88148, 88149, 88150, |

| |adverse effects | |Z12.4 |88151, 88152, 88153, 88154, 88155, |

| |CS Procedure: Allow regardless of age or frequency, unless | | |88164, 88165, 88166, 88167, 88174, |

| |limited in the plan document | | |88175, Q0091 |

|Dental Caries Prevention |Requirement: |04/01/2005 | |99188 |

|(p.k.a. Oral Health |Oral fluoride supplementation at currently recommended doses |05/01/2015 | |Probably billed through PBM or |

|Assessment) |to preschool children older than 6 months of age | | |could be dispensed in the pharmacy |

| |Oral fluoride supplementation at currently recommended doses | | |or physician’s office |

| |to children ages 6 months to age 5 | | | |

| |Application of fluoride varnish by primary care physician to | | | |

| |the primary teeth of all infants and children starting at the | | | |

| |age of primary tooth eruption to age 5 | | | |

| |CS Procedure: | | | |

| |Allow without age limitation | | | |

|Depression Screening |Requirement: Ages 12-18 |03/01/2010 |ICD9 – V79.0 |99420 |

| |CS Procedure: Allow without review of age or medical necessity| |ICD10 – Z13.89 | |

|Developmental Problems |Requirement: Newborn, 3-5 days, 1, 2, 4, 6, 12, 15, 24 |09/23/2010 | |96110, 96111 |

| |months, then annually ages 3-21 | | | |

| |CS Procedure: Allow with CPT codes given and any routine | | | |

| |diagnosis without age limitation | | | |

|Gonorrhea Medication |Requirement: Prophylactic medication for newborns |07/01/2012 |ICD9 – V20.0, V20.31, |Probably billed through PBM or |

| |CS Procedure: Allow with diagnosis codes given | |V20.32 |could be dispensed in the pharmacy |

| | | |ICD10 – Z00.110, Z00.111, |or physician’s office |

| | | |Z76.1 | |

|Hearing |Requirement: Newborn, Ages 4, 5, 6, 8, 10 |07/01/2009 |ICD9 – V20.2, V20.3, |92585, 92586, 92587, 92588 |

| |CS Procedure: Allow at any age, up to age 10 unless unlimited | |V20.31, V20.32 | |

| |by the plan document | |ICD10 – Z00.110, Z00.111, | |

| | | |Z00.129 | |

|Height, Weight and Body Mass |Requirement: Newborn, 3-5 days, 1, 2, 4, 6, 9, 12, 15, 18, |09/23/2010 | | |

|Index (BMI) |24, 30 months, then annually ages 3-21 | | | |

| |CS Procedure: Allow without age limitation | | | |

|Hepatitis B Infection |Requirement: Non-pregnant adolescents in high risk of |05/01/2015 | | |

|Screening |infection | | | |

|HIV (human immunodeficiency |Requirement: Adolescents at increased risk |09/23/2010 |ICD9 – V08 |86689, |

|virus) |CS Procedure: Allow without review | |ICD10 – Z21 |86701, 86702, 86703, |

| | | | |87390, |

| | | | |87534, 87535, 87536, |

| | | | |S3645 |

|Hypothyroidism - Congenital |Requirement: Newborn |03/01/2009 |ICD9 – V20.3, V20.31, | |

|(Lack of Thyroid Secretions) |CS Procedure: Allow without age limitation | |V20.32 | |

| | | |ICD10 – Z00.110, Z00.111 | |

|Iron Supplement |Requirement: Prescription strength iron supplementation of |05/01/2007 – |ICD9 – V20.2, V78.0 | |

|(no cost sharing terminated |any type when used to prevent or treat iron deficiency anemia |09/01/2016 |ICD10 – Z00.129, Z13.0 | |

|for plan years on or after |in children 6-12 months |(no cost sharing | | |

|09/01/16) |CS Procedure: Diagnosis code would allow without age |terminated for plan | | |

| |limitation |years on or after | | |

| |(no cost sharing terminated for plan years on or after |09/01/16) | | |

| |09/01/16) | | | |

|Lead Screening |Requirement: 12 and 24 months, risk assessment 6 months-age 6|09/23/2010 | |83655 |

| |Side Note: an assessment is estimating the likelihood of | | | |

| |adverse effects | | | |

| |CS Procedure: Allow with any routine diagnosis, no age | | | |

| |limitation | | | |

|Lipid Disorders (Cholesterol |Requirement: Ages 18-21, Risk assessment ages 2, 4, 8, |09/23/2010 | | |

|and Triglycerides) |annually ages 10-17 | | | |

| |Side Note: an assessment is estimating the likelihood of | | | |

| |adverse effects | | | |

| |CS Procedure: Allow without age limitation | | | |

|Obesity Screening and |Requirement: For ages 6 and older |01/01/2011 |ICD9 – 278-278.03, V77.8 |97802, 97803, 97804, |

|Counseling to Improve Weight |CS Procedure: Allow without review for ages 6 through 17 | |ICD10 – E66.01, E66.2, |98960, |

| | | |E66.3, E66.9, Z13.2, |99401, 99402, 99403, 99404, |

| | | |Z68.3-Z68.45 |99411, 99412, 99420 |

|PKU (Phenylketonuria – An |Requirement: Newborn |03/01/2009 |ICD9 – V77.3 |84030 |

|Inherited Metabolic |CS Procedure: Allow without age limitation | |ICD10 – Z13.228 | |

|Deficiency) | | | | |

|Sexually Transmitted |Requirement: |10/01/2009 |ICD9 – V65.45 |99401, 99402, 99403, 99404 |

|Infection (STI) Prevention |Counseling sessions to prevent STIs |09/01/2015 |ICD10 – Z71.89 | |

|Counseling |High intensity behavioral counseling for all sexually active | | | |

| |adolescents at increased risk for STIs | | | |

| |CS Procedure: Allow without review | | | |

|Sickle Cell Anemia and Trait |Requirement: Newborn |09/01/2008 | | |

|(Hemoglobinopathies) |CS Procedure: Allow without age limitation for diagnosis V78.2| | | |

| |or procedures 85660 or S3850 | | | |

|Skin Cancer Counseling |Requirement: For ages 10 – 24 |05/01/2013 | | |

| |CS Procedure: If billed with a wellness exam, would pay as | | | |

| |preventive health | | | |

|Tuberculin testing |Requirement: Risk assessment 1, 6, 12, 18, 24 months, then |09/23/2010 |ICD9 – V01.1, V03.2, V74.1|86480, 86481, 86580 |

| |annually ages 3-21 | |ICD10 – Z11.1, Z20.1, Z23 | |

| |Side Note: an assessment is estimating the likelihood of | | | |

| |adverse effects | | | |

| |CS Procedure: Allow without age or frequency restriction | | | |

|Visual Acuity Screening |Requirement: One time between the ages of 3 and 5 to detect |01/01/2012 | | |

| |presence of amblyopia | | | |

| |CS Procedure: Allow without age or frequency restriction | | | |

|Vision screening |Requirement: 2 times per year for newborns and well-child |09/23/2010 |ICD9 – V72.0 |92002, 92004, 92012, 92014, 92081, |

| |visits. Risk assessment ages 7, 9, 11, 13, 14, 16 , 17, 19, | |ICD10 – Z01.00, Z01.01 |92082, 92083, 99172, 99173, 99174 |

| |20, 21 | | | |

| |Screening Ages 3, 4, 5, 6, 8, 10, 12, 15, 18 | | | |

| |Side Note: an assessment is estimating the likelihood of | | | |

| |adverse effects | | | |

| |CS Procedure: Allow without age or frequency restriction | | | |

|Child Immunizations |Requirement / CS Procedure (when deviation exists) |Effective Date |Diagnosis Code(s) |Procedure Code(s) |

|Diphtheria, Tetanus, |Requirement: |09/23/2010 | |90701 |

|Pertussis |TDAP type at 11-12 years |06/07/2016 | | |

| |2 months, 4 months, 6 months, between 15-18 months, between 4-6 | | | |

| |years and 11-12 years | | | |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Flu (Influenza) |Requirement: 2 doses for the first flu season, then annually |09/23/2010 | |90655, 90656, 90657, 90658, 90660, |

| |CS Procedure: Allow without age or frequency restrictions | | |90662 |

|Haemophilus influenza type |Requirement: 2 months, 4 months, 6 months, between 15-18 months|09/23/2010 | |90644, 90645, 90646, 90647, 90648 |

|B (HIB) |CS Procedure: Allow without age or frequency restrictions | | | |

|Hepatitis A |Requirement: Between 12 and 23 months (2 doses) |09/23/2010 | |90632, 90633, 90634, 90636 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Hepatitis B |Requirement: Birth, between 1 and 2 months, between 6-18 months|09/23/2010 | |90731, 90740, 90746 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|HPV (human papilloma virus)|Requirement: Between 9-18 years (3 doses) |09/23/2010 | |90649, 90650 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Measles, Mumps, Rubella |Requirement: 12 months, between 4-6 years |09/23/2010 | |90705, 90707, 90708, 90710 |

|(MMR) |CS Procedure: Allow without age or frequency restrictions | | | |

|Meningococcal |Requirement: Between 11-18 years |09/23/2010 | |90466, 90620, 90664, 90733, 90734 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Pneumococcal (PCV) |Requirement: 2 months, 4 months 6 months, between 15-18 months |09/23/2010 | |90669, 90732 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Inactivated Polio |Requirement: 2 months, 4 months, between 6-18 months |09/23/2010 | |90712, 90713 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Rotavirus |Requirement: 2 months, 4 months, 6 months (Rotateq) 2 months, |09/23/2010 | |90680, 90681 |

| |4 months (Rotarix) | | | |

| |CS Procedure: Allow without age or frequency restrictions | | | |

|Varicella (Chickenpox) |Requirement: Between 12-15 months, between 4-6 years |09/23/2010 | |90716 |

| |CS Procedure: Allow without age or frequency restrictions | | | |

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