blue cross blue shield mammogram coverage

Blue Cross and Blue Shield of Louisiana joins other healthcare organizations in reminding Louisianians how important it is to know your personal health risks and ask your doctor about screening. Scenario 2: Your claim for emtricitabine/tenofovir (generic Truvada) or Apretude is not paying at 100% and you are using it for PrEP. We'll be completing scheduled maintenance on Sunday (3/5) from 12 a.m. until 6 a.m. Blue Connect may be unavailable during this time. Ordering physicians for Blue Cross NC members must obtain prior approval prior to scheduling an imaging exam for outpatient diagnostic, non-emergent services. Heres a deeper dive on the potential benefits and risks of a 3D mammogram. Breast cancer is the most widely found cancer in U.S. women, next to skin cancer. Some state or federal mandates [e.g., Federal Employee Program (FEP)] prohibits plans from Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Illinois. BRCA is an abbreviation for the BReast CAncer gene, which is an inherited trait. Issuance of prior approval is not a guarantee of payment. Non-Discrimination Statement and Foreign language Access. Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. It happens in both men and women, but breast cancer in men is not common. http://www.breastcancer.org/symptoms/understand_bc/statistics Service & Support; FAQs; Find an Event; Public Service Recognition; About Us; 1 results found for search term : mammograms. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Health Plans for Individuals and Families, Get a Quote for Individual and Family Plans, Non-Discrimination Policy and Accessibility Services, medications and OTC nicotine replacement therapy (NRT), refer to the CDCs posted schedule of immunizations for more information. The protection of your privacy will be governed by the privacy policy of that site. Find your ideal accommodation from hundreds of great deals and save with www.trivago.com Does this prior approval impact Blue Medicare HMO and Blue Medicare PPO? Some sites may require you to agree to their terms of use and privacy policy. A high BMI can be a warning sign for potential health problems. If physicians have questions about the Blue Cross NC diagnostic imaging management program, they should contact their local Network Management representatives. Theyll also look for early signs of breast and cervical cancer. Achieving this requires that we reduce the number of imaging examinations that do not add diagnostic value for members. Do practicing North Carolina physicians have input into the program? - Ebonie from Chicago, IL [Humana HMO] "I used to have Blue Cross Blue Shield and we didn't have a copay for normal mammograms but even then, I still paid $1700 because the no-cost mammogram lead to ultrasound, another mammogram, and an MRI. "To put it in perspective, the dose of radiation is lower than that of a chest x . CT, CTA MRI, MRA, PET and echocardiography scans related to an emergency room visit, hospital stay or outpatient observation do not require prior approval. By continuing to use this website, you consent to these cookies. Annual physical exams and other preventive services are free when you use a Preferred provider. If you don't see your insurance plan listed, please contact our Insurance Hotline at 469-398-4099 or email us at insuranceinfo@solismammo.com. Reimbursement Policy: Screening and Diagnostic Mammography & 3D Tomosynthesis Effective Date: April 15, 2017 Last Reviewed Date: February 14, 2023 Purpose: Provide guidelines for the processing of claims for multiple mammograms, CAD and Digital Breast Tomosynthesis (DBT) to align with recent changes to CMS' position on screening and diagnostic mammograms and to define what a mammographic . If you have an HMO or POS plan, there are some additional services you'll need approval for. endstream endobj startxref Here's how to interpret your BMI: Below 18.5: underweight. Women between the ages of 40 and 49 should talk to their doctor about when they should start getting mammograms. Breast Cancer Mammography Screening Age 35-39 . The program will apply to members covered by the following plans: Blue Options SM (group PPO plan), Blue Option HRA (group PPO plan), Blue Options HSA (group and individual PPO plan), Classic Blue (Group CMM plan), Dental Blue (group and individual dental plan), Blue Advantage (individual PPO), Short Term Health Care (individual CMM plan). If something is found in a preventive screening mammogram, the screening is still at no cost to the member. Register Now, Ancillary and Specialty Benefits for Employees. Imaging costs have come to the forefront for employers and health plans because they have been growing at a faster rate than other segments of medical expenditures. No family history, no risk. No lump, no cancer. Mammograms use very small doses of radiation and the risk of harm is very low. For screening examination to detect breast cancer in. Fewer false alarms reduce unnecessary re-testing along with stress and worry. Women ages 35-39 can receive one baseline mammogram(four views). Technical Information Mammograms use very small doses of radiation and the risk of harm is very low. Fraud and Abuse No lump, no cancer. Did you know preventive health measures and screenings can prevent 85% of illness and disease, and are covered at no cost for many plans? Has Blue Cross NC considered disallowing self-referrals? Hysterectomies are not performed solely for sterilization so are not covered as preventive. Heres everything you need to know about it. Since being a carrier is relatively uncommon, doctors usually only test people with a family history of breast or ovarian cancer. Cost estimates are based only on the coverage you have with us. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association . Insurance. Mammograms: Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. Who can physicians call if they have questions? Blue Cross and Blue Plus plans cover these eligible preventive services for women ages 12-64, with no member cost sharing when obtained at the in-network level*: Alcohol and substance misuse counseling. There are significant concerns about patient safety involved in the increased exposure to radiation due to diagnostic imaging procedures. We use cookies on this website to give you the best experience and measure website usage. The program does not currently apply to FEP, Medicare Supplemental or Medicare Prescription Drug Plans. Description: Screening for cervical cancer. For transgendered individuals, you have access to medically appropriate preventive services. Standard 2D mammograms take two pictures of the breast. The policies were effective September 1, 2010 for Blue Medicare HMO and Blue Medicare PPO plans. should confirm that a prior approval number has been issued. These benefits are available for members of non-grandfathered individual health insurance plans. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Learn the facts, then schedule an appointment today! What are the goals of the diagnostic imaging management program? Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. What process is in place for unfavorable determinations? Be sure you're taking full advantage of your coverage. Should a member request One of the goals of this program is to help contain health care costs. Through a preventive exam and routine health screenings, your doctor can determine your current health status and detect early warning signs of more serious, costly problems. How does Blue Cross NC ensure that the program does not negatively impact patient care, divert physicians from the practice of medicine or compromise the patient/physician relationship? They can help detect breast cancer up to three years before it can be felt. Coverage is subject to the specific terms of the member's benefit plan. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the . Copy. But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. $100 outpatient benefits. Learn more about our non-discrimination policy and no-cost services available to you. Technical Information Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%. For evaluation of identified lesion, mass or abnormality in breast in. Most breast cancers are found in women 50 years old and older. Most basis mammogram screenings are covered by your health plan. Who reviews requests for diagnostic imaging prior approval? They can help detect breast cancer up to three years before it can be felt. What information is required to request prior approval? Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breasts, implants); A breast cancer risk assessment (by the Gail risk or other validated breast cancer risk assessment models) that identifies the individual as having a lifetime risk of 20% or greater of developing breast cancer (approve annually); Two (2) or more first degree relatives (parents, siblings, and children) have history of breast cancer; Individuals with histories of extensive chest irradiation (usually as treatment for Hodgkin's or other lymphoma.) Breast Cancer and Early Detection: What Women Need to Know. Mammograms are a key component of a womens preventative care. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. Why did Blue Cross NC implement a diagnostic imaging management program? Pays in addition to your other coverages. When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Click on a service to see any limits or exclusions. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. Check out the changes and updates to our plan in 2023. Provided by an in-network doctor or facility (urgent care facility, outpatient clinic or ambulatory surgery center), Filed by your doctor as a preventive care visit, Identified as preventive care under the Affordable Care Act (ACA), In women age 2129 with cervial cytology (pap test) every 3 years, A Pap test and high-risk human papillomavirus (hrHPV) test every 5 years or. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the . Among the preventive health benefits for our members, Regence covers mammography at 100 percent for women. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. %%EOF 2023 Blue Cross Blue Shield of North Dakota, Please wait while your form is being submitted, Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. As an example, women get regular mammograms at no cost to them as a preventive screening. Blue Cross NC created a Diagnostic Imaging Advisory Group, which includes North Carolina physicians who order and render radiology services and representatives of major medical organizations, to allow for medical community feedback. Find A Doctor Or Hospital In Your Network. Coverage is subject to the specific terms of the member's benefit plan. This can get confusing, so call your health plan before you go. You should get screenings every one or two years, depending on your doctor's advice. They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. Negotiated rates with providers can change, therefore, changing the estimate. Routine gynecological visits. Genetic counseling and evaluation can help determine if youve inherited a BRCA mutation. Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. Most Florida Blue plans cover annual screening mammograms for women age 40 and older for as low as a $0 copay. BlueCross BlueShield of South Carolina. All Rights Reserved. seen only in single view mammogram without ultrasound correlation); Previous positive breast biopsy within the previous four (4) months and no intervening previous breast MRI; Evaluation of palpable lesion on physical examination and not visualized on ultrasound or mammogram and MRI guided biopsy considered; For evaluation of axillary node metastasis or adenocarcinoma with normal physical examination and normal breast mammogram; Individuals diagnosed with biopsy-proven lobular neoplasia or atypical ductal hyperplasia (ADH); Personal history of or first-degree relative with Le-Fraumeni syndrome (TP53 mutation), Cowden syndrome (PTEN) or Bannayan-RileyRuvalcaba syndrome (BRRS). You must be at least 18 years old to submit a request. Please send us your question so a licensed agent can contact you. Your doctor can help you choose a facility thats convenient for you. The policies were effective for diagnostic imaging services performed on or after February 15, 2007 for Blue Cross NC commercial plans. You are leaving this website/app ("site"). Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. Blue Cross and Blue Shield Association . Out of network billing can lead to unexpected charges. Most breast cancers are found in women 50 years old and older. Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health professional, at least every three years. Necesita su ID de usuario? Cancer screenings like colonoscopies and mammograms. Yes, they will cover annual mammograms if they are suitable to age. The protection of your privacy will be governed by the privacy policy of that site. Disponible nicamente en ingls. The issue of return on investment and appropriateness of guidelines will be continually addressed as part of the evaluation of the program. Internal Medical Policy Committee 11-19-2020 Annual Review-Title changed slightly, Internal Medical Policy Committee 11-23-2021 Annual Review-no changes in criteria, Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria. Still, the overall benefit of 2D and 3D breast cancer screening outweigh any potential risks linked to radiation exposure. Provider Manual . Coverage Information. This information is a reference tool and does not guarantee payment of any claims. Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Yes, as of September 1, 2010, all Blue Medicare HMO and Blue Medicare PPO members participate in the program. Preventive Care Guidelines. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Breast cancer mammography screenings for women over age 40; Colorectal cancer screening for adults over age 45; . The following contraceptive methods (devices and associated procedures, such as device removal, and pharmaceutical contraceptives) for women with reproductive capacity: Emergency contraception (i.e., morning after pill, Plan B, ella), Effective 8.1.22, one annual subscription to, a prescription from an in-network provider that includes the name of the app, Natural Cycles fertility app, Injections (only covered as preventive for Medoxyprogesterone Acetate 150 mg, which is the only drug and dosage used for contraception), Oral contraceptives (all generic contraceptives will be covered as preventive; brand oral contraceptives will continue to require member cost sharing (e.g., deductible, copay, and/or coinsurance) View a complete, OTC contraceptives (female condoms, all products; sponges, all products; spermicides, all products, male condoms effective 1.1.23), Sterilization procedures including tubal ligation (tying of fallopian tubes) and salpingectomy (removal of fallopian tubes). Bacteriuria screening for pregnant women. However, about 72% of women with BRCA1 and about 69% of women with BRCA2 will develop breast cancer by the age of 80. Hospitals and freestanding imaging centers that perform the imaging services cannot obtain the approval. Please utilize the checklist below as a guideline to ensure you have all the necessary information before requesting prior approval: For complex cases, more information may be necessary, including: The diagnostic imaging management process is based upon AIM clinical practice guidelines, developed from consensus opinion in medical practice and integration of medical information from multiple sources, including: The prior approval number will be valid for 30 days from the date issued - not the date of service requested. The scans take detailed X-ray images from many angles. Barium enema is a covered service but not at 100% so you may have out of pocket costs. Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. Preventive care includes routine well exams, screenings and immunization intended to prevent or avoid illness or other health problems. Frequency: May vary based on your health so ask your doctor, Certain breast pumps for pregnant and post-partum women, One manual or electric breast pump purchase per pregnancy is covered, Benefit available during third trimester (starting 11.1.16) or after member has delivered the baby, Breast pumps come with certain supplies, such as tubing, shields and bottles, Breast pumps must be purchased from participating Durable Medical Equipment (DME) vendors. When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. Combined together, the X-rays create a three-dimensional picture of each breast. Diagnostic mammograms more frequently than once a year, if medically necessary. For most women, mammogram technology is still considered the best way to detect breast abnormalities and cancers early. To capture them, the breast is pulled away from the body, compressed and held between two glass plates. %PDF-1.5 % We believe that it is critical to carefully examine the appropriate use of outpatient, nonemergency diagnostic imaging procedures to make sure that the benefit of the procedure outweighs the risk. Blue Cross and Blue Shield Service Benefit Plan brochures, https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815. No. If you get benefits from your employer, you may also have these benefits. Usage Agreement Blue Medicare HMO and Blue Medicare PPO (as of September 1, 2010). In addition, some sites may require you to agree to their terms of use and privacy policy. It's important to note that your provider has the right to code and bill services according to his or her viewpoint. Domestic Travel When traveling outside of Vermont you may need access to medical services. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. As a result, 3D mammograms lower the number of false alarms. Some buy into dangerous myths about breast cancer. We cover mental health services for transgender and gender-diverse members, whether or not you have a mental health diagnosis. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. You have coverage from another insurance plan in addition to your Blue Cross and Blue Shield of Nebraska coverage. Approve annually starting at age 30; Individuals with known BRCA mutation. MRI of the breast may be considered medically necessary for individuals with silicone implants whenEITHERof the following are met: MRI of the breast may be considered medically necessary for individuals with no history of known breast cancer, MRI of the breast may be considered medically necessary for individuals with history of known breast cancer. Additional Screenings for High-Risk Women Health plans are offered by Blue Shield of California. . Understand the difference between preventive and diagnostic. . Preventive Care. For more information, view our privacy policy. Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD. The Diagnostic Imaging Management Advisory Group is asked to help develop future phases of the diagnostic imaging program, including addressing over-utilization by self-referring physicians as necessary. Issuance of a prior approval number is not a guarantee of payment. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Doses, recommended ages and recommended populations vary. 18.5 - 24.9: healthy weight. Blue Cross and Blue Shield Federal Employee Program Yesterday at 1:00 PM Simple yet warm, this customizable sheet pan lemon-roasted fish . Place of service exclusion: Sterilization coverage applies to all places of service, with the exception of the Emergency Room.