Women ages 35-39 can receive one baseline mammogram (four views). A Pap test every 3 years or. Mammograms are the best way to screen for breast cancer and can detect cancer up to three years before other signs and symptoms appear. Learn the facts, and then schedule an appointment today! No. You usually need to get tested every 3 to 5 years. 30 and above: obese. These benefits are available for members of non-grandfathered individual health insurance plans. Mammogram screening $0 Once per year Nutrition therapy services $0 Ongoing if high risk The cost of many screenings and checkups is covered at 100% with no out of pocket costs for you and those on your plan. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. Breast cancer is the most widely found cancer in U.S. women, next to skin cancer. 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. http://www.breastcancer.org/symptoms/understand_bc/statistics Breast Cancer. One option is Adobe Reader which has a built-in screen reader. Salpingectomy for sterilization purposes will be covered as preventive effective 7.1.22, Trans-dermal contraceptives (i.e., contraceptive patches), Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider, If there is a medical reason you cannot take a generic contraceptive, your doctor should review this, Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. After your annual preventive exam, you will receive an Explanation of Benefits (EOB) from Blue Shield of California to notify you that your claim has been processed. Health Insurance Tax Information; Transparency in Coverage; Mental Health Parity; Teledentistry Services Covered; . Your doctor can help you choose a facility thats convenient for you. The remaining 40% are out-of-pocket costs. Since being a carrier is relatively uncommon, doctors usually only test people with a family history of breast or ovarian cancer. Still, over the past decade, there have been advances in mammogram technology. . 2020. . Download the BCBSIL App. Under the benefits of certain plans, the following diagnostic imaging services that are received in an outpatient setting, such as in a medical office, the outpatient department of a hospital or at a freestanding imaging center may require prior approval (for dates of service on or after February 15, 2007 for Blue Cross NC commercial plans and September 1, 2010 for Blue Medicare HMO and Blue Medicare PPO plans): Prior approval is not required when these procedures are performed in an emergency room, hospital (related to an inpatient or observation stay), urgent care center or ambulatory surgical center. Coverage Information. 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. 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. One of the goals of this program is to help contain health care costs. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. Annually about 220,000 women are diagnosed with breast cancer. Your member ID card is your key to using your medical plan benefits. See your doctor andrefer to the CDCs posted schedule of immunizations for more information. During your visit, your doctor will perform a clinical breast exam. You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. If you discuss new medical concerns or a current illness, the entire visit may be considered a medical treatment visit and would not be covered as preventive care. Forgot Password? What is a Religious Organization:A religious organization refers to all employer groups defined under federal law that may limit or not cover contraceptive services due to the type of organization or that have a religious objection to these services. Are you going to reimburse providers for the savings Blue Cross NC will incur? Not all employer groups participate in the diagnostic imaging management program. BlueCross BlueShield of South Carolina. Who reviews requests for diagnostic imaging prior approval? 2021 plans will be available for purchase beginning on November 1, 2020. Has Blue Cross NC considered disallowing self-referrals? Currently, under the Patient Protection and Affordable Care Act Annual Checkups and certain preventive . Prior approval is required by all facilities or settings that offer outpatient, nonemergency diagnostic imaging services. Focusing on the right test at the right time for the right patient could save time and mone and increase productivity. We use cookies on this website to give you the best experience and measure website usage. Most basis mammogram screenings are covered by your health plan. The following preventive services and immunizations do not apply to all health plans administered or insured by Blue Cross and Blue Shield of Alabama. This happens by feeling breast tissue for any lumps or abnormal areas. Standard 2D mammograms take two pictures of the breast. 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. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Preventive care includes routine well exams, screenings and immunization intended to prevent or avoid illness or other health problems. Screening for Cervical Cancer Thanks in part to preventive screenings, there are approximately 2.8 million breast cancer survivors in the U.S. as of 2016. To learn if your patient's plan requires prior approval for these services, please reference the diagnostic imaging procedures page. Learn the facts, then schedule an appointment today! Inscribirse ahora! No family history, no risk. 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). 25 - 29.9: overweight. Reimbursement Guidelines - Alphabetical Index, Reimbursement Guidelines - Categorical Index, Become a Blue Cross NC Provider or Recredential, Contact Information for Regional Network Management, Responsibilities of Primary Care Physicians (PCP) in 2008, IPP Coordination of Benefits Questionnaire. No coverage for routine physical examinations. Annual physical exams and other preventive services are free when you use a Preferred provider. Select Your Gender. BSC6.07 Digital Breast Tomosynthesis. So why do so many women put off their mammograms? Breast Cancer Mammography Screening Age 35-39 . Please update your browser if the service fails to run our website. Diagnostic mammograms more frequently than once a year, if medically necessary. Bacteriuria screening for pregnant women. Among the preventive health benefits for our members, Regence covers mammography at 100 percent for women. And that means no copays, coinsurance or payment toward your deductible. 3D mammograms may be covered by your health plan. Our goal is to review diagnostic imaging tests to determine if each test is clinically appropriate for the specific situation. They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. NRT through QuitlineNC is available without a prescription. To view this file, you may need to install a PDF reader program. Mental Health Services. Currently, about 12% of women will develop breast cancer at some point in their lifetime. Who can physicians call if they have questions? 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. Copy. We have an obligation to our members to provide quality care at an affordable price. Some preventive care services require that you meet . 0 Data shows that roughly 30-40% of imaging exams are considered clinically inappropriate or noncontributory. The USPSTF recommends biennial screening mammography for . Mammograms are one of the best ways to find it early. This is very important in clinical decision making as alternative therapies may be selected based upon the results obtained from the MRI. It is important to note that these services are free only when delivered by a doctor or other . For women age 30-65. 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. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Your doctor can help determine your risk level and what steps you should take. %PDF-1.5 % If you provide a phone number, an agent may call you to make sure that you received the information and to answer any questions that you might have. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Learn more about our non-discrimination policy and no-cost services available to you. For example, at the Kapiolani Medical Center [ 1] in Aiea, Hawaii, where the full . Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. All women 40 or older should ask their doctor about when to start getting mammograms and how often theyre needed. What imaging procedures require prior plan approval? No coverage for oral contraceptive devices. mammogram for women between ages 35-39. We can send you an email with information on our health care plans. For evaluation of identified lesion, mass or abnormality in breast in. Find an in-network doctor for preventive care. Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD. Standard 2D mammograms take two pictures of the breast. It often forms in the tubes that carry milk to the nipple (ducts) and in glands that make milk (lobules). Who Should Get It: Sexually active women 24 years or younger and in women 25 years or older who are at increased risk of infection, Who Should Get It:Women at high risk of infection or pregnant women, Who Should Get It:Persons at high risk of acquiring HIV, Who Should Get It:Women to age 65 or older if at increased risk, Who Should Get It:Women at high risk of infection and pregnant women, Who Should Get It:Age 18 and older, including pregnant women, Who Should Get It:Women of reproductive age, Who Should Get It:Age 18 and older; when pregnant, Who Should Get It:Women, dependent children up to age 26, pregnant women, Who Should Get It:Women aged 40 to 60 years with normal or overweight body mass index (BMI) of 18.5 - 29.9. Echocardiography studies (effective for both Commercial and Blue Medicare HMO\PPO lines of business as of January 2, 2014), Member identification number, name, date of birth, and health plan, Imaging exam(s) being requested (body part, right, left or bilateral), Patient diagnosis (suspected or confirmed), Clinical symptoms/indications (intensity/duration), Results of treatment history (previous tests, duration of previous therapy, relevant clinical medical history), American Institute of Ultrasound in Medicine (AIUM), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) and National Coverage Determinations (NCD), Promoting and guiding the selection of the most appropriate and cost-effective diagnostic imaging services, Encouraging standardization of medical practice patterns and reducing variation in clinical evaluation, Curtailing the performance of inappropriate diagnostic imaging studies, Advocating biosafety issues, including reduction of clinical radiation exposure (for CT and plain film radiography), Enhancing quality of health care for diagnostic imaging studies using evidence-based medicine and outcomes research from numerous resources. Women ages 35-39 can receive one baseline mammogram(four views). Obesity screenings. Blue Cross and Blue Shield of Illinois . Best Answer. Theyre covered, lifesaving and nothing to fear. The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the President in March 2010. . Your dashboard may experience future loading problems if not resolved. 1 If you have gotten one dose of Zostavax vaccine for shingles, you should also get the two doses of Shingrix vaccine. Covered: Getting screened wont break the bank. You can also visit our Mental Health Resource . 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. The protection of your privacy will be governed by the privacy policy of that site. Diagnostic care includes care or treatment when you have symptoms or risk factors and your doctor wants to diagnose them. Of the 4 million women age 40 to 65 in Texas, 2.6 million . If there is a medical reason you cannot use a generic bowel preparation medication, your doctor should review this. Additionally, we cover computer-assisted detection for those women who seek an extra level of screening for breast cancer. For evaluation of breast lesion, identifying whether single or multi-focal, in individual with diagnosed breast cancer; For evaluation of suspicious mass, lesion, distortion or abnormality of breast in individual with history of breast cancer. By using X-rays, they create two-dimensional images of the breast to spot suspicious tissue that may be cancerous. All Rights Reserved. The program does not currently apply to FEP, Medicare Supplemental or Medicare Prescription Drug Plans. We use cookies on this website to give you the best experience and measure website usage. BATON ROUGE - October is Breast Cancer Awareness Month. For transgendered individuals, you have access to medically appropriate preventive services. Your Florida Blue Medicare health plan includes a mammogram screening every year for women age 40 and over. Easy: Keeping up with your screenings is an important task, even in your busy life. Individuals with a known history of Breast Cancer: Approve initial staging, with treatment [within three (3) months], and yearly surveillance for detection of recurrence or a new cancer. You must also receive prior approval from us. It happens in both men and women, but breast cancer in men is not common. Side-to-side and top-to-bottom images . Nothing to fear: Its normal to feel scared before any medical procedure, but theres nothing to worry about! If so, it should not impact the ability of members to receive these tests. Yes. Most Florida Blue plans cover annual screening mammograms for women age 40 and older for as low as a $0 copay. Hysterectomies are not performed solely for sterilization so are not covered as preventive. Separately billed services are not covered under preventive services and are subject to the normal benefits based on place of service, may have them as a covered benefit, but not as a preventive care benefit covered at 100%, may not have contraceptive benefits through your group medical plan, If either of these two scenarios apply to you, have your provider fill out and fax. Your coverage information in the palm of your hand. Telephonic counseling available by calling QuitlineNC at 844-8NCQUIT. Healthy tissue may appear suspicious and cancerous tissue can be masked. Breast Screening Benefit "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography . If you have a positive fecal blood test (gFOBT or FIT or Cologuard) or visualization test (CT colonography or sigmoidoscopy), your doctor may order a follow up colonoscopy. Scroll down to see some common services that may or may not be covered during a preventive care visit. Others have a false sense of . should confirm that a prior approval number has been issued. Doses, recommended ages and recommended populations vary. Some providers charge more, and some offer an uninsured discount. While 3D mammograms show some promise in better health outcomes, there isnt enough research to advocate them over 2D mammograms. The diagnostic imaging management program impact is low; why did Blue Cross NC implement it? This screening is no cost to you. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. Side-to-side and top-to-bottom images are made. File is in portable document format (PDF). What are the goals of the diagnostic imaging management program? Blue Cross and Blue Shield Association . BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. We apologize for any inconvenience. %%EOF Only ordering physicians can obtain a prior plan approval number. endstream endobj startxref Blue Shield of California is an independent member of the Blue Shield Association. Achieving this requires that we reduce the number of imaging examinations that do not add diagnostic value for members. Blue Cross NC is very aware of the concerns about self-referral. The following are the recommended vaccines for women that are covered with no out of pocket cost. Genetic counseling and evaluation can help determine if youve inherited a BRCA mutation. Preventive Care Guidelines. Use the subsidy calculator to enter your own . hbbd``b` Colorectal Cancer . Health plans are offered by Blue Shield of California. Some buy into dangerous myths about breast cancer. All rights reserved. Women ages 40 and older can receive a mammogram (four views) each calendar year. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. What imaging procedures do NOT require prior approval? We will work with the physician community through our Diagnostic Imaging Management Advisory Group to assure that there is no negative impact on the quality of patient care as a result of this initiative. Examples of these services include: Initial evaluation. Here's how to interpret your BMI: Below 18.5: underweight. BCBSIL Provider Manual June 2020 2 . HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. It may also be used to depict residual disease after neoadjuvant chemotherapy. This information is a reference tool and does not guarantee payment of any claims. - 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. As always, be sure to check your specific plan coverage and see an in-network provider. Description: clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. By slowing this growth and containing costs through a proactive diagnostic imaging management program, we anticipate costs savings over time. For example, women who have a family history of breast, cervical or ovarian cancer can be tested for the BRCA1 or BRCA2 genes. Confirmation of silicone gel-filled breast implant ruptures, when this diagnosis cannot be confirmed by mammography or breast ultrasound; For postoperative evaluation of silicone breast implant complications. Learn more about our non-discrimination policy and no-cost services available to you. Privacy Policy Screenings, tests and other preventive care services Preventive care service Cost . Mammograms are for older women. One option is Adobe Reader which has a built-in reader. Hospitals and freestanding imaging centers that perform the imaging services cannot obtain the approval. Issuance of prior approval is not a guarantee of payment. Approve annually starting at age 30. Fraud and Abuse Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. The good news is that mammograms can catch cancer early, when its easiest to treat, even if you dont have any symptoms. Provider consultation prior to the colonoscopy procedure is covered at 100%. All rights reserved. Frequency: In women age 21-29 with cervial cytology (pap test) every 3 years. For preoperative evaluation for known breast cancer when surgery planned within thirty (30) days; Evaluation of more than two (2) lesions to optimize surgical planning when requested by surgeon or primary care provider on behalf of surgeon who has seen the individual. Understand the difference between preventive and diagnostic. Since their introduction, standard mammograms also called screening mammograms have helped save countless lives. 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 . Counseling. Scenario 2: Your claim for emtricitabine/tenofovir (generic Truvada) or Apretude is not paying at 100% and you are using it for PrEP. Based on clinical criteria, AIM will issue a prior approval number or will forward requests to a nurse or physician if they require further review. $300 inpatient benefits. The policies were effective for diagnostic imaging services performed on or after February 15, 2007 for Blue Cross NC commercial plans. FDA-approved tobacco cessation prescription. The cost estimate changed prior to your care. The AIM physician reviewer may contact the ordering physician to discuss the case in greater detail within two (2) business days of receipt of the request. The policies were effective September 1, 2010 for Blue Medicare HMO and Blue Medicare PPO plans. Reproduction without authorization from Blue Shield of California is prohibited. Starting June 1, 2022, this follow up colonoscopy will be covered at 100%. Non-Discrimination Statement and Foreign language Access. Talking with your healthcare provider about the . Fortunately, only about 1 in 400 people have a BRCA gene. Approve annually starting at age 30; Individuals not yet tested for BRCA gene, but with known BRCA mutation in first degree relative. Fargo, N.D., 58121. Please review the terms of use and privacy policies of the new site you will be visiting. By Regence. 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. Blue Cross NC is the fourth insurer in the state to implement a diagnostic imaging management program, and we understand that our physician community has vital feedback that will help make our program successful.
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