Preventive Guidelines
NOTICE: The preventive guidelines displayed below are intended as a billing resource for providers. Benefits and services are subject to change by Alliant. To understand if you or your patient qualifies for these benefits, refer to the Member’s Certificate of Coverage or call Client Services at (800) 811-4793.
As new recommendations and guidelines for preventive care are published by the government sources identified above, they will become covered under the member’s Contract for plan years which begin one year after the date the recommendation or guideline is issued or on such other date as required by the Affordable Care Act. The plan year, also known as a policy year for the purposes of this provision, is based on the calendar year.
Preventive Guidelines
| Preventive Health Care Benefit | Frequency | Age Limits | ICD 10 Codes | CPT/HCPCS | Other Requirement(s) | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Abdominal Aortic Aneurysm Screening | 1 per lifetime | Men Ages 65-75 | Group 3 | 76706 | N/A | |||||
| Abnormal Blood Glucose and Diabetes Screening and Counseling as part of cardiovascular risk assessment. Adults aged 40 to 70 who are overweight or obese; women with history of gestational diabetes mellitus | 1 per year Adults 1 per year Pregnant | Ages 40 to 70 Unless pregnant then no age limit | Group 1 Group 15 | 82947 or 83036 | N/A | |||||
| Alcohol Substance Misuse | 1 per year | None | Group 8 | 99408, 99409, G0396, G0397, G0442, G0443 | N/A | |||||
| Anemia Screening | 1 per year Pregnant | None | Group 1 | 80055, 85013, 85014, 85018, 85025, 85027 or 80081 | N/A | |||||
| Aspirin use for the prevention of preeclampsia for women over 12 weeks gestation and who are at high risk for preeclampsia | N/A | N/A | Not applicable, administered through Pharmacy | N/A | OTC Aspirin (81 mg) is dispensed to member with a physician order at a participating pharmacy with no cost-sharing. | |||||
| Bacteriuria Screening: using urine culture in pregnant persons. | 1 per year Pregnant | None | Group 15 | 87081, 87084, 87086 or 87088 | N/A | |||||
| BART Testing | 1 per lifetime | None | Any Diagnosis | 81162, 81164, 81166, 81167 | Prior Authorization Required. | |||||
| Bilirubin Screening: infants with gestational age of 35 weeks or greater | 1 per lifetime | Ages 0 - 8 Days | Group 1 | 82247, 88720 | Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth. | |||||
| BRCA Counseling | 1 per year | None | Group 1 Group 9 Group 10 | 96040, S0265 | No additional requirement. | |||||
| BRCA Testing | 1 per lifetime | None | Any Diagnosis | 81212, 81215, 81216, 81217, 81163, 81165 | Prior Authorization Required. | |||||
| Breast Cancer Chemoprevention | 1 per year for visit. No limit of fills on risk-reducing medications dispensed to member with a physician order with no cost-sharing | Female 35 years or older | Group 9 | 99401, 99402 or is included in wellness visit 99385, 99386, 99387, 99395, 99396, 99397 | This recommendation applies to asymptomatic women aged 35 years or older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ. Risk-reducing medications are dispensed to member with a physician order with no cost-sharing. | |||||
| Breast Cancer Screening: MRI | 1 per year | Female 40 years of age or older unless considered high risk then is 39 years of age or younger | Group 1 Group 10 Group 9 | 77048, 77049 | Prior Authorization Required. | |||||
| Breast Cancer Screening: Mammograms and Digital Breast Tomosynthesis | 1 per year | Female 40 years of age or older unless considered high risk then is 39 years of age or younger | Group 1 Group 10 Group 9 | 77063, 77067 | N/A | |||||
| Breastfeeding support, supplies, and counseling (Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for breastfeeding equipment) | See Other Requirements | None | Group 5 | 99401, 99402, 99403, 99404, S9443, E0602, E0603, A4281, A4282, A4283, A4284, A4285, A4286, *E0604, K1005 | Counseling covered at 100% through in-network providers (i.e., OB/GYNs, midwives, facilities); one breast pump provided per pregnancy through in-network DME providers. 99401-99403, 99404** are to be used in the absence of a wellness visit. *E0604 is covered as rental only. | |||||
| Cervical cancer/HPV screening | Women 21-29 years of age every 3 years by cytology and age 30-65 years of age every 3 years with cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) | Women 21-29 years of age every 3 years by cytology and age 30-65 years of age every 3 years with cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) | Group 1 Group 10 | 88141, 88142, 88143, 88144, 88145, 88146, 88147, 88148, 88149, 88150, 88151, 88152, 88153, 88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, Q0091, S0601-S0613, 87624, 87625 | N/A | |||||
| Chlamydial Infection Screening | 1 per year and 1 per year pregnant | Women 24 and Older unless pregnant in which case there is no age limit | Group 2 Group 15 | 87110, 87270, 87320, 87490, 87491, 87801, 87810, 86631, 86632, 87492, 36415, 36416 | N/A | |||||
| Cholesterol Abnormalties/Lipid Disorder Screening | 1 per year | See other requirements | Group 1 | 80061, 82465 or 83718 | Men 35 and older (for lipid disorders) *men younger than 35 (for ages 20-35 for lipid disorders if they are at increased risk for coronary heart disease)Women 20 and older (for lipid disorders if they are at increased risk for coronary heart disease) See also: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. | |||||
| Colorectal Cancer Screening | ||||||||||
| Colorectal Cancer Screening - Colonoscopy | 1 per 10 years unless high risk in which case is 1 per 2 years | Ages 45-75 - Routine Ages 18-75 - High Risk | Group 13 Group 14 | 45378, 45380, 45381, 45382, 45384, 45385, 45388, S0285, G0105, G0121 | N/A | |||||
| Colorectal Cancer Screening - CT Colonography | 1 per 5 years | Ages 45-75 - Routine Ages 18-75 - High Risk | Group 13 Group 14 | 74263 | Prior Authorization Required. | |||||
| Colorectal Cancer Screening - FIT | 1 per year | Ages 45-75 - Routine Ages 18-75 - High Risk | Group 13 Group 14 | 82274 | N/A | |||||
| Colorectal Cancer Screening - Sigmoidoscopy | 1 per 5 years unless high risk in which case is 1 per 2 years | Ages 45-75 - Routine Ages 18-75 - High Risk | Group 13 Group 14 | 45330, 45331, 45333, 45334, 45335, 45338, 45346, G0104 | N/A | |||||
| Colorectal Cancer Screening - Fecal DNA (Cologuard) | 1 per 3 years | Ages 45 - 75 - Routine | Group 13 | 81528 | N/A | |||||
| Colorectal Cancer Screening - FOBT | 1 per year | Ages 45-75 Routine Ages 18-75 High Risk | Group 13 Group 14 | 82270 | N/A | |||||
| Contraceptive methods and counseling | N/A | N/A | Group 1 | Part of preventive visit (99384, 99385, 99386, 99394, 99395, 99396), 99401, 99402, A4264, J1050, J7296, J7298, J7300, J7301, J7306, J7307, 11981,11982, 11983, 57170, 58300, 58565, 58600, 58605, 58611, 58615, 58671, 58670, 96372, 11976, 58301, 00851 | For contraceptive medications and devices covered at 100% under the pharmacy benefit see Formulary Lookup Tool. Also, 99401-99402 may be used for counseling in the absence of a wellness visit. | |||||
| Depression Screening Adults (screening for depression, including pregnant and postpartum women, when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up) Adolescents (screening 12-18 yr olds for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy [cognitive-behavioral or interpersonal], and follow-up) | 1 per year | Ages 12 years and above | Group 1 Group 2 | G0444 | N/A | |||||
| Developmental Screening | 1 annually | Up to age 18 | Group 1 Group 2 | 96110 | N/A | |||||
| Emotional/behavioral assessment | 1 per year | None | Group 1 Group 2 | 96127 | N/A | |||||
| Fall Prevention (Exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.) | 3 annual - any combination | Ages 65 and Older | Group 4 | 97110, 97112, 97116, 97530, G0151, G0157, G0159, S9131 and S9476. | N/A | |||||
| Flouride Varnish | 1 quarterly | Up to age 5 | Group 1 | 99188 | N/A | |||||
| Folic Acid supplementation for all women planning or capable of pregnancy All women planning or capable of pregnancy to take a daily supplement containing 0.4 - 0.8 mg [400-600 mcg] of folic acid | N/A | N/A | Not applicable, administered through Pharmacy | N/A | OTC folic acid supplements are dispensed to member with a physician order with no cost-sharing. | |||||
| Gestational Diabetes Mellitus (GDM) Screening in asymptomatic pregnant women after 24 weeks of gestation. | 1 per pregnancy | None | Group 15 | 82950 | N/A | |||||
| Gonorrhea Screening Women who are sexually active that are at increased risk for infection [if they are young or have other individual or population risk factors]) Pregnant Women | 1 per year 1 per year Pregnant | None | Group 2 Group 15 | 87590, 87591, 87801 and 87850 | N/A | |||||
| Group B strep testing performed one time during pregnancy | 1 per pregnancy | None | Group 15 | 87081 | N/A | |||||
| Hemoglobinopathies Screening (for sickle cell disease in newborns) | 1 per lifetime | Ages 0 - 8 Days | Z00.110 | 83020, 83021, 85660 and S3620 | Service is typically performed in the birth facility or as part of a wellness office visit. | |||||
| Hepatitis B Screening (in pregnant women at first prenatal visit and in persons at high risk for infection.) | 1 per year Persons at high risk for infection and 1 per year Pregnant | Ages 13-79 unless pregnant then at any age | Group 2 Group 15 | 87340, 80055 , 80081, 36415, 36416 | N/A | |||||
| Hepatitis C Virus (HCV) Screening (for persons at high risk for infection.) The USPSTF also recommends offering one-time screening for HCV infection to adults aged 18 to 79. | 1 every 10 years | Ages 18 - 79 | Group 2 | 86803, G0472, 36415, 36416 | N/A | |||||
| High Blood Pressure Screening (Recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment) | Ages 18 and Older | Group 1 may be used with 99385-99387 or 99395-99397. For coverage of 93784, 93786, 93788, 93790, A4670 must bill with R03.0. | 99385, 99386, 99387 or 99395, 99396, 99397 For ambulatory blood pressure monitoring use 93784, 93786, 93788, 93790 For home blood pressure monitor use A4670 | 99385-99387 or 99395-99397 are part of the wellness visit | ||||||
| HIV Infection Prevention with Preexposure prophylaxis (Persons at high risk of acquiring HIV. Offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition, including monitoring required prior to initiation of therapy and during drug therapy). | HIV PrEP Codes | For medications covered at 100% please use the Formulary Lookup Tool on AlliantPlans.com | ||||||||
| HIV Screening | 1 per year Persons at high risk and 1 per year Pregnant | Ages 15 - 65 unless pregnant then at any age | Group 2 Group 15 | G0432, G0433, G0435, G0475, S3645, 36415, 36416, 86701, 86703, 87389, 86702 | N/A | |||||
| Iron supplementation in children (routine iron supplementation for asymptomatic children 6-12 mo of age who are at increased risk for iron deficiency anemia) | N/A | N/A | Not applicable, administered through Pharmacy | N/A | N/A | |||||
| Lead Screening | 1 per year | Ages 7 and Under | Group 1 | 83655 | N/A | |||||
| Lung Cancer Screen (LDCT) | 1 per year | Ages 50 - 80 | Group 3 | 71271 | Prior Authorization Required. | |||||
| Lung Cancer Screen (LDCT) Counseling | 1 per year | Ages 50 - 80 | Group 3 | G0296 | N/A | |||||
| Nutritional Counseling Healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors. (Recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.) | 1 - Preventive 4 - Medically Necessary | Ages 6 and Over | Group 6 Group 7 | 97802, 97803, 97804, 99401, 99402, 99403, 99404, S9470, G0447, G0473 | N/A | |||||
| Osteoporosis Screening - Bone density CT | 1 every two years | Age 65 and Older unless high risk in which case is age 20 and older | Group 11 Group 12 | 77078 | Prior Authorization | |||||
| Osteoporosis Screening - Bone density tests | 1 every two years | Age 65 and Older unless high risk in which case is age 20 and older | Group 11 Group 12 | 76977, 77080, 77081, 77085 | N/A | |||||
| PKU Screening (in newborns) | 1 per lifetime | Ages 0 - 8 Days | Group 1 | 84030 | N/A | |||||
| Prophylactic medication for gonorrhea: newborns (ocular topical medication for all newborns against gonococcal ophthalmia neonatorum) | N/A | N/A | Not applicable, administered through Facility | N/A | This medication is generally administered to newborn at birth facility. | |||||
| Prostate Screening | 1 Annually | Males Ages 50 - 70 | Group 1 Group 10 | G0102, G0103 | N/A | |||||
| Rh(D) blood typing and antibody testing for all pregnant women | 2 per pregnancy - The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative. | Group 15 | 86901, 86850, 36415, 36416 | |||||||
| Sensory Screening - Hearing (beyond newborn screening) | Covered annually | Ages infant through 18 years | Group 1 | 99382, 99383, 99384, 99385, 99392, 99393, 99394, 99395, 92551, 92558, 92586, 92650, 92651 | May be part of wellness visits. | |||||
| Sexually Transmitted Infections Counseling (recommends high-intensity behavioral counseling to prevent STIs for all active adolescents and for adults at increased risk for STIs) | 1 Annually | None | Group 2 | G0445 | N/A | |||||
| Syphilis Screening | 1 per year Persons at increased risk and 1 per year Pregnant | None | Group 2 Group 15 | 36415, 36416, 80055, 80081, 86592, 86593, 86780 | N/A | |||||
| Tobacco Cessation | 1 Annually | None | Group 1 Group 3 | 99406, 99407 | N/A | |||||
| Tuberculosis Screening for persons at higher risk | 1 annually | All ages | Group 1 | 86580 | N/A | |||||
| Vaccines Recommended by the Centers for Disease Control, Diphtheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Haemophilus Influenzas Type B, Hepatitis A , Hepatitis B, Influenza, Pneumococcal, Meningococcal, Human Papillomavirus (HPV), Inactivated Poliovirus, Rotavirus, Varicella, Tetanus-Diphtheria /Tetanus-Diphtheria Acellular Pertussis, Herpes Zoster (Shingles), Adult and Child & Adolescent Immunization Schedules (for persons aged 0-6 years, 7-18 years, and "catch-up schedule") Refer to the CDCs posted schedule of immunizations http://www.cdc.gov/vaccines/schedules/index.html | N/A | N/A | Group 1 | N/A | Doses, recommended ages and recommended populations vary. All recommended routine immunizations will be allowed with no cost share. | |||||
| Visual Acuity Screening | 1 annually | Up to Age 18 | Group 1 | 99173, 99174, 99177 | N/A | |||||
| Wellness Exams Include the following service when applicable: - Developmental Surveillance - History and assessment of the physical state (height, weight, BP (blood pressure), BMI (body mass index)) - Screening for congenital hypothyroidism (In newborns) - Screening and counseling for interpersonal and domestic violence The USPSTF recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer women who screen positive to ongoing support services - UV light exposure counseling for persons age 6 months to 24 years | Follows Pediatric Guidelines for ages 3 and under for ages 4 and older is 1 annually and for age 11 and older is 1 annually with availability to see OBGYN for preventive care. | See Frequency Covered at Preventive Benefit for details | Group 1 | G0438, G0439, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, S0302, 80050, 81002, 81003, 84437, 84443, 82951, 82952, 86704, 86705, 86706, 86900, 87522, 99000, 80053, 36415, 36416 | N/A | |||||
