Skip to main content

2023 Preventive Coverage Changes

Date:
September 16, 2022

To: All Providers

Contracts Affected: Commercial and Medicare Advantage

Beginning January 1, 2023, we will be aligning with Highmark’s preventive services schedule determined by the USPSTF, AAP Bright Futures, HRSA Women’s Preventive Health, CDC General Immunization Schedule, and CMS Preventive Schedule.

This means some labs previously considered preventive with a $0 cost-share for your Highmark Blue Shield of Northeastern New York Commercial and Medicare Advantage patients will now be subject to your patients’ regular cost-shares and deductibles only when the lab is billed with a medical diagnosis.

Preventive Labs

For your Commercial Highmark BSNENY patients, the following labs will be covered under preventive benefits with a $0 cost-share January 1, 2023:

Commercial Preventive labs for adults include:

  • Cholesterol/lipid screening
  • Glucose screening for screening for diabetes
  • Hepatitis B screening
  • Hepatitis C screening
  • Latent tuberculosis screening
  • Chlamydia, Gonorrhea, HIV, Syphilis screening
  • Overweight or obese BMI- hemoglobin A1c or glucose
  • PAP and HPV screening
  • PSA Screening

Commercial Preventive labs for children/adolescents include:

  • Lead screening
  • Anemia screening hemoglobin and hematocrit
  • Newborn blood screening and bilirubin
  • Cholesterol/lipid screening
  • Hepatitis B screening
  • Hepatitis C screening
  • Latent tuberculosis screening
  • Overweight or obese BMI- hemoglobin A1c or glucose
  • Chlamydia, Gonorrhea, HIV, Syphilis screening

Additional Commercial Preventive labs for pregnancy include:

  • Urine culture
  • Rh typing/antibody
  • Gestational diabetes screening
  • Syphilis and HIV screening
  • Hepatitis B screening

Commercial Diagnostic Labs

The following labs will be considered diagnostic and must include a medical diagnosis code beginning January 1, 2023. These labs will be subject to your patients’ regular cost-share.

Some of these labs may have previously been considered preventive with a $0 cost-share in 2022 but will no longer be considered preventive in 2023.

Please note: Labs no longer on the preventive schedule that are billed without a medical diagnosis code may be subject to full patient responsibility.

Diagnostic lab examples that must include a medical diagnosis code include:

  • TSH testing
  • CBC
  • CMP
  • Urinalysis
  • Vitamin D
  • HCG/pregnancy testing
  • FOBT (other than colorectal neoplasm screening)
  • Antibody testing
  • Hemoglobin A1c (for normal weight)
  • Diagnostic PAP smear
  • Vaginal infection tests

Medicare Advantage ONLY

For your Highmark BSNENY Medicare Advantage patients, some services have been added to the preventive schedule or have had a coding change.

The following services that have been added as a preventive service with a $0 cost-share for your Highmark BSNENY Medicare Advantage patients include:

  • Cervical cancer screening with Human Papillomavirus (HPV)
  • Colorectal cancer screening (Screening CT virtual colonoscopy and FIT Kit)
  • Pelvic exam (annual GYN exam)

The preventive services that have had a change in coding guidance include:

  • Bone mass measurements – code 78359 will no longer be considered preventive
  • Hepatitis C screening – codes 86803 and 86804 will no longer be considered preventive

For a complete list of preventive services and corresponding coding guidance, please visit the CMS Medicare preventive services schedule here.

If you have additional questions about these changes, please contact your practice account manager. 

Recent Articles

  • 2023 Medicare Advantage Drug Formulary and Pharmacy Prior Authorization Changes
    Beginning January 1, 2023, some of your Highmark Blue Shield of Northeastern New York (Highmark BSNENY) Medicare Advantage patients may be affected by changes to Highmark’s pharmacy drug formulary. In early December, please be on the lookout for letters detailing select formulary changes affecting your Medicare Advantage patients. Medication-related prior authorization requests will be submitted to and reviewed by our Utilization Management (UM) team. In this article, you can review 2023 formulary updates along with information about the Medicare Advantage pharmacy prior authorization review process as all Medicare Advantage members move onto Highmark’s system.
  • Enhancements to NaviNet Prior Authorization Experience
    We will begin rolling out enhancements to our utilization management (UM) tool through NaviNet on January 1, 2023. These enhancements are intended to streamline your experience by enabling faster reviews and greater transparency around the status of your authorization requests. Here, you can find tips for submitting NaviNet authorization requests on the new platform.
  • Prior Authorization Changes Postponed for Musculoskeletal Procedures and Pain Management, Molecular and Genomic Testing, and Radiation Oncology
    We are postponing the authorization requirement changes for some musculoskeletal (MSK) procedures and interventional pain management, molecular and genomic testing, and radiation oncology services that we announced last month. The requirement updates, which will be managed by eviCore, will not take effect until late Q1 or early Q2. Webinars will be scheduled to orient providers to the eviCore programs before they take effect.
  • Reimbursement Reduction for Cassette-Based X-Ray Imaging
    Effective February 27, 2023, the reduction applied to the reimbursement for X-ray services using computerized radiography cassette-based imaging (FY modifier) is increasing from 7% to 10% (3% additional reduction) for your Highmark Blue Shield of Northeastern New York commercial and Medicare Advantage patients. In this article, you can access the updated reimbursement policy.
  • Two Injectables to Require Prior Authorization Beginning March 1
    On March 1, 2023, two injectable drugs will require prior authorization. Here, you can view the codes as well as additional information about prior authorizations.

Working with Us

Additional Resources

We want to hear from you! Have a topic request for the next Blue Bulletin? Email us

Stay in Touch! Sign up to receive emails for provider news and information