Engage with your patients annually to ensure their health and wellness initiatives are kept current.
Preventive Screening Services are made available to all patients without Prior Authorization limitations when performed by a PCP or by a Preferred Specialist physician. Services are most cost-effectively provided through outpatient-based resources such as provider offices and free-standing imaging and surgical centers, limiting the use of hospital-based services to only those whose health would be adversely impacted by using freestanding sites of service.
The following Preventive Screening services, when delivered by PCPs or Preferred Specialists, require no Prior Authorization when performed in the office or in a freestanding (non-hospital affiliated) center*.
*For Mammography Screening, no Prior Authorization is required at any health plan in-network site of service, although, non-hospital radiology centers are preferred.
| Preventive Service | Procedure Codes | ICD-10 Diagnosis Codes | Coverage Parameters |
| Preventive Screening | 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 92002, 92004, 92012, 92014, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, S0620, S0621, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99483, G0402, G0438, G0439, G0463, T1015 | All | Frequency: One procedure code/member/year Ages: All Gender: M/F |
| Examination and Counseling Services | 96160, 96161 | All | Frequency: One procedure code/member/year Ages: All Gender: M/F |
| Examination and Counseling Services | 99401, 99402, 99403, 99404 | All | Frequency: One procedure code/member/year Ages: All Gender: M/F |
| Examination and Counseling Services | G0513, G0514 | All | Frequency: One procedure code/member/year Ages: All Gender: M/F |
| Abdominal Aortic Aneurysm (AAA) Screening | 76706 | F17.200, F17.201, F17.203, F17.208, F17.209, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A, Z13.6, Z87.891 | Frequency: 1x/lifetime Ages: 65-75 years Gender: M |
| Alcohol Screening | 99408, 99409, G0396, G0397, G0442, G0443 | Z13.89 | Frequency: 1x/year Ages: All Gender: M/F |
| Autism, Psychosocial/Behavioral and Developmental Screening | 96110, 96127 | Z00.121, Z00.129, Z13.89, Z13.41, Z13.42 | Frequency: 1x/year Ages: 0 – 21 years Gender: M/F |
| Anemia (General) via Quest Labs | 85025 | Z00.00, Z00.01, Z00.121, Z00.129, Z01.411, Z01.419, Z00.5, Z00.70, Z00.71, Z00.8 | Frequency: 1 x/year Ages: All Gender: M/F |
| Breast Supplemental Screening and Diagnostic Imaging | 76641, 76642, 77058, 77059 | None | Frequency: 1 x/year Ages: All Gender: F |
| Breast Tomosynthesis | 77061, 77062, 77063, G0279 | None | Frequency: 1 x/year Ages: 40 years and over Gender: F |
| Chlamydia Screening via Quest Labs | 86631, 86632, 87110, 87140, 87270, 87320, 87490, 87491, 87492, 87800, 87801, 87810 | All | Frequency: 1x/year Ages: All Gender: F |
| Colon Cancer Screening (Anesthesia and Ancillary Services) | 00812 | All | Frequency: Once every 5 years Ages: 50-75 years Gender: M/F In Network Anesthesiology Services Required |
| Colon Cancer Screening | 44388, 44389, 44391, 44392, 44394, 45300, 45303, 45305, 45308, 45309, 45315, 45317, 45320, 45330, 45331, 45333, 45338, 45346, 45378, 45380, 45382, 45384, 45385, 45388, 74263, 45379, 45381, 45386, 45389, 45390, 45391, 45392, 45393, 45398, 44390, 44393, 44397, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 74261, 74262, 45332, 45334, 45335, 45337, 45339, 45340, 45341, 45342, 45347, 45349, 45350 | Z00.00, Z00.01, Z12.12, Z12.10, Z12.11, Z80.0, Z83.71, Z83.79 | Frequency: Once every 10 years Ages: 50 – 75 years Gender: M/F |
| Colorectal Cancer Screening | G0104, G0105, G0106, G0120, G0121, G0122 | K50.00, K50.011, K50.014, K50.018,K50.019, K50.10, K50.111, K50.114, K50.118, K50.119, K50.80, K50.811, K50.814, K50.818, K50.819, K50.90, K50.911, K50.914, K50.918, K50.919, K51.20, K51.211, K51.214, K51.218, K51.219, K51.30, K51.311, K51.314, K51.318, K51.319, K51.80, K51.811, K51.814, K51.818, K51.819, K51.90, K51.911, K51.914, K51.918, K51.919, K52.1, K52.89, K52.9, Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79 | Frequency: Once every 5 years Ages: 50 – 75 years Gender: M/F |
| Colon Cancer Screening (Pathology) via Ameripath or Quest Labs | 88305 | Z00.00, Z00.01, Z12.12, Z12.10, Z12.11, Z80.0, Z83.71, Z83.79 | Frequency: once every 5 years Ages: 50 – 75 years Gender: M/F |
| Colon and Colorectal Cancer Screening (Stool For Occult Blood – Lab Test) | 82270, 82274, G0328 | Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79 | Frequency: 1X year Ages: 50 – 75 years Gender: M/F |
| Colorectal Cancer Screening (Cologuard ® Lab Test) | 81528, G0464 | Z12.10, Z12.11, Z12.12, Z80.0 | Frequency: once every 3 years Ages: 50 – 85 years Gender: M/F of average cancer risk |
| Developmental Screening | 96110, G0451 | Z13.41, Z13.42, Z13.89 | Frequency: 1x/year Ages: up to age 18 Gender: M/F |
| Diabetes Screening via Quest Labs | 82947, 82948, 82950, 82951, 82952, 83036 | Z13.89, Z13.41 | Frequency: 1x/year Ages: All Gender: M/F |
| Diabetes Screening: Gestational via Quest Labs | 82947, 82948, 82950, 82951, 82952, 83036, 83036, 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156 | Z13.42 | Frequency: 2x/year Ages: All Gender: F |
| Diabetic Retinal Screening | 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, S0620, S0621, S3000, 2022F, 2024F | E10.1, E10.6, E11.1, E11.2, E11.6 | Frequency: 1x/year Ages: All Gender: M/F |
| Spirometry | 94010, 94014, 94015, 94016, 94060, 94070, 94375 | J42, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.9 | Frequency: 1x/year Ages: All Gender: M/F For diagnosis of COPD |
| Gynecological Exam | 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397 | Z01.411, Z01.419 | Frequency: 1x/year when provided by OB/Gyn or PCP Ages: All Gender: F |
| Hearing Screening | 92551, 92552, 92553, 92568, 92585, 92586 | Z00.00, Z00.01, Z01.10, Z01.12, Z00.121, Z00.129 | Frequency: 1x/year Ages: 0 – 21 years Gender: M/F |
| Hepatitis B Screening via Quest Labs | 86704, 86706, 87340, 87341, G0499 | All | Frequency: 1x/year Ages: All Gender: M/F |
| Hepatitis C Screening via Quest Labs | 86803, G0472 | Z20.5, Z20.6, Z20.828, Z72.89 | Frequency: 1x/year Ages: 50+ Gender: M/F |
| HIV Screening via Quest Labs | G0432, G0433, G0435, G0445, G0475 | Z00.00, Z00.01, Z00.121, Z00.129, Z11.3, Z11.4, Z11.59, Z20.6, Z22.6, Z22.8, Z22.9, Z71.7 | Frequency: Unlimited Ages: All Gender: M/F |
| Human Papilloma Virus (HPV) Screening via Quest Labs | 87623, 87624, 87625 | Z00.00, Z00.01, Z00.121, Z00.129, Z00.8, Z01.411, Z01.419, Z11.51, Z12.4 | Frequency: 1x/year Ages: All Gender: F |
| Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests via Quest Labs (paid when billed by a laboratory only) | G0476 | Z00.00, Z00.01, Z01.411, Z01.419, Z11.51, Z12.4 | Frequency: 5x/year Ages: 30 – 65 Gender: F |
| Lead Screening via Quest Labs | 83655 | Z00.121, Z13.88, Z77.011 | Frequency: 1x/year Ages: 0-6 years Gender: M/F |
| Lipid Screening via Quest Labs | 80061, 82465, 83718, 83719, 83721, 84478 | Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.220, Z13.6, Z13.228, Z13.818 | Frequency: 1x/year Ages: All Gender: M/F |
| Lung Cancer Screening at a free standing Radiology Center | G0296, G0297 | F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891, Z12.2 | Frequency: 1x/year Ages: 55 + Gender: M/F |
| Mammography Screening all Sites of Service | 77067, 77065, 77066, G0202, G0204, G0206 | Z12.31, Z12.39 | Frequency: 1x/year Ages: 40+ years Gender: F |
| Newborn Screening: Hearing | 92558 | All | Frequency: 1x/year Ages: 0-3 months Gender: M/F |
| Newborn Screening: Hypothyroidism | 84437, 84443 | Z13.29 | Frequency: 1x/year Ages: 0-3 months Gender: M/F |
| Newborn Screening: PKU | 84030, S3620 | Z13.0, Z13.21, Z13.228, Z13.29 | Frequency: 1x/year Ages: 0-3 months Gender: M/F |
| Newborn Screening: Sickle Cell Disease | 83020, 83021, 83051, S3850 | Z13.0, Z13.21, Z13.228, Z13.29 | Frequency: 1x/year Ages: 0-3 months Gender: M/F |
| Osteoporosis Screening via office or free standing imaging center | 76977, 77078, 77080, 77081, 77085, G0130, 76977, 77078, 77080, 77081, 77085, G0130 | All | Frequency: Every 23 months Ages: 60+ years Gender: F |
| Pap Smear via Quest Labs | 87081, 87205, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, Q0091 | Z00.00, Z00.01, Z01.411, Z01.419, Z11.3, Z12.4, Z12.72, Z12.0, Z12.79, Z12.89, Z77.110, Z77.111, Z77.112, Z77.118, Z77.122, Z77.123, Z77.128, Z77.21, Z77.22, Z77.9, Z91.82, Z91.89, Z92.89 | Frequency: 1x/year Ages: All Gender: F |
| Pregnancy, Bacteriuria Screening via Quest Labs | 81007, 87086, 87088 | All | Frequency: Unlimited Ages: All Gender: F |
| Pregnancy, Blood Count via Quest Labs | 85025, 85027 | All | Frequency: Unlimited Ages: All Gender: F |
| Prostate Cancer Screening via Quest Labs | 84152, 84153, 84154, G0102, G0103 | Z12.5 | Frequency: 1x/year Ages: 40+ Gender: M |
| Obstetric panel (includes HIV testing) via Quest Labs | 80081 | All | Frequency: 1x/year Ages: All Gender: F |
| Pregnancy, Hepatitis B Screening via Quest Labs | 87340, 87341 | All | Frequency: 1x/year Ages: All Gender: F |
| Pregnancy, Rh (D) Typing via Quest Labs | 86901 | All | Frequency: Unlimited Ages: All Gender: F |
| Pregnancy Screening Panel via Quest Labs – Includes Hepb, Blood Count, Rh (D), Syphilis | 80055 | All | Frequency: 1x/year Ages: All Gender: F |
| Syphilis Screening via Quest Labs | 86592, 86593, 86780, 87164, 87166, 87285 | All | Frequency: 1x/year Ages: All Gender: M/F |
| TB Testing | 86480, 86580 | R76.11, R76.12, Z00.121, Z00.129, Z11.1, Z20.1 | Frequency: 1x/year Ages: All Gender: M/F |
Vision Screening in Children | 99172, 99173 | Z00.121, Z00.129, Z01.00, Z01.01 | Frequency: 1x/year Ages: 0-21 years Gender: M/F |
| 99174, 99177 | Z00.121, Z00.129, Z01.00, Z01.01 | Frequency: 1x/year Ages: 1-4 years Gender: M/F | |
| Immunization administration | 90460, 90461, 90471, 90472, 90473, 90474, G0008, G0009, G0010 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria, tetanus (DT) | 90702 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria, tetanus, acellular pertussis (DTaP) | 90700 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria, tetanus, acellular pertussis (Tdap), age 7 or older | 90715 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria, tetanus, acellular pertussis, Hepatitis B, polio (DtaP-HepB-IPV) | 90723 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age | 90696 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria, tetanus, acellular pertussis, HIB, polio (DTaP- HIB-IPV) | 90698 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Diptheria preservative free, tetanus (Td), age 7 or older | 90714, 90715 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Hepatitis A | 90632, 90633, 90634 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Hepatitis A/Hepatitis B Combo | 90636 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Hepatitis B | 90739, 90740, 90743, 90744, 90746, 90747, G0010 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Hepatitis B/HIB Combo | 90748 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Herpes Zoster Vaccine | 90736, 90750 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| HIB (Hemophilus influenza b) | 90647, 90648 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| HPV (Human Papillomavirus) Vaccine | 90649, 90650, 90651 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Influenza (flu) Vaccine | 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90672, 90674, 90673, 90682, 90685, 90686, 90687, 90688, 90689, 90756, G0008, Q2034, Q2035, Q2036, Q2037, Q2038 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Measles-Mumps-Rubella (MMR) Virus Immunization | 90707 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Measles-Mumps-Rubella- Varcella (MMRV) | 90710 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Meningitis Vaccine | 90733, 90734 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Meningococcal Vaccine | 90620, 90621 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Meningitis-HIB Vaccine | 90644 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Pneumococcal Vaccine, 13 valent | 90670, G0009 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Pneumococcal Vaccine– Over age 2 and adult | 90732, G0009 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Poliomyelitis, inactivated (IPV) Immunization | 90713 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Rotavirus Vaccine | 90680, 90681 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Rubella Immunization Status | 86762 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Varicella | 90716 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
| Zoster | 90750 | All | Provider must adhere to FDA/CDC age/frequency/gender guideline. |
