The program does not currently apply to FEP, Medicare Supplemental or Medicare Prescription Drug Plans. Tests that do not meet national clinical guidelines will not be approved. To learn if your patient's plan requires prior approval for these services, please reference the diagnostic imaging procedures page. Prior approval is required by all facilities or settings that offer outpatient, nonemergency diagnostic imaging services. 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. Inscribirse ahora! Be sure you're taking full advantage of your coverage. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the President in March 2010. . Preventive Care Guidelines. There are many easy-to-use BMI calculators online, such as this example from the Centers for Disease Control and Prevention.*. You should get screenings every one or two years, depending on your doctor's advice. 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. The diagnostic imaging management program impact is low; why did Blue Cross NC implement it? A high BMI can be a warning sign for potential health problems. They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. Others have a false sense of . Breast Cancer. Your doctor will advise on recommended immunizations that can protect against a number of serious diseases. Fraud and Abuse However, your group may decide to delay the effective date for coverage until your group's plan . 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. Mammograms are the best way to screen for breast cancer and can detect cancer up to three years before other signs and symptoms appear. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Check out the changes and updates to our plan in 2023. You will be required to pay the plan's physician office copayment or coinsurance. Scenario 2: Your claim for emtricitabine/tenofovir (generic Truvada) or Apretude is not paying at 100% and you are using it for PrEP. Technical Information Generally, practicing consistently with national evidence-based guidelines is expected to reduce errors and liability. 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. Blue Medicare HMO and Blue Medicare PPO (as of September 1, 2010). Page 2 of 33. time of service to determine coverage or non -coverage of these services as it applies to an individual member. All rights reserved. For women age 30-65. 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? Preventive Care. When were Blue Cross NC's diagnostic imaging prior approval policies effective? Heres a deeper dive on the potential benefits and risks of a 3D mammogram. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. All Rights Reserved. SOURCES: Your browser is not supported. They can help detect breast cancer up to three years before it can be felt. Breast cancer is the second leading cause of cancer deaths among women in the U.S. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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. As a result, 3D mammograms lower the number of false alarms. Currently, about 12% of women will develop breast cancer at some point in their lifetime. Please send us your question so a licensed agent can contact you. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. recipe is no mess, no fuss and all flavor. Necesita su ID de usuario? Mammography is highly regulated by the Food and Drug Administration, the Mammography Quality and Standards Act and other governing organizations like the American College of Radiology. Blue Cross and Blue Shield Service Benefit Plan brochures, https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Your doctor will collect a sample of cells from your cervix to test for any abnormal or precancerous cells. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. 140 0 obj <>stream Scenario 1: Brand Truvada, Viread, or Descovy may be made available if you are clinically unable to use generic Truvada. The following preventive services and immunizations do not apply to all health plans administered or insured by Blue Cross and Blue Shield of Alabama. Log In to the Shopping Cart, Need to Make a Payment? hrHPV test only every 5 years. 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. Breast Screening Benefit "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography . Women ages 40 and older can receive a mammogram (four views) each calendar year. 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. Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g. Approve annually starting at age 30; Individuals not yet tested for BRCA gene, but with known BRCA mutation in first degree relative. It is important to note that these services are free only when delivered by a doctor or other . If you have an HMO or POS plan, there are some additional services you'll need approval for. Should a member request Anemia screening for pregnant women. Some sites may require you to agree to their terms of use and privacy policy. Accessibility Plus, your medical plan covers 100% of the costs for preventive health services when care is provided through network providers. Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. Thanks in part to preventive screenings, there are approximately 2.8 million breast cancer survivors in the U.S. as of 2016. Side-to-side and top-to-bottom images . Linked Apps. (EOB) from Blue Shield of California to notify you that your claim has been processed. We recognize that any requirements for prior plan approval for procedures place an administrative burden on physicians, and we continually evaluate such programs to assure that they deliver on promised savings to members while attempting to minimize the impact on provider offices. 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. Make sure to get all the screenings and vaccines recommended for your age and gender. 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. Cost estimates are based only on the coverage you have with us. Routine gynecological visits. Health Plans for Individuals and Families, Get a Quote for Individual and Family Plans, Non-Discrimination Policy and Accessibility Services. Ordering physicians may also contact the AIM physician reviewer at any time during the authorization process. There has been an error with your submission. 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. Your doctor can help you choose a facility thats convenient for you. There are significant concerns about patient safety involved in the increased exposure to radiation due to diagnostic imaging procedures. Mammograms use very small doses of radiation and the risk of harm is very low. Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. Forgot Password? Frequency: In women age 21-29 with cervial cytology (pap test) every 3 years. 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. Examples of these services include: Initial evaluation. Dynamic contrast material-enhanced MRI may be used to monitor response of a tumor to neoadjuvant chemotherapy used to shrink the tumor before surgery. Will the diagnostic imaging management program increase the risk of malpractice? 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. Diagnostic care includes care or treatment when you have symptoms or risk factors and your doctor wants to diagnose them. Breast MRI should be bilateral except for those with a history of mastectomy or when the MRI is being performed expressly to further evaluate or follow findings in one (1) breast. To view this file, you may need to install a PDF reader program. New health problems discussed with your doctor during your visit, Diagnoses that need to be addressed such as high blood pressure, diabetes, skin rash, and headaches, Breast cancer mammography screenings for women over age 40, Colorectal cancer screening for adults over age 45, Cholesterol screening for adults of certain ages or at higher risk, Additional testing and follow-up procedures if abnormalities are found during mammography or colorectal cancer screenings, Request for a vitamin Dlevel check to test for bone and muscle development and function, Request for a vaccination filter test to determine acceptable amounts of vaccine antibodies in the bloodstream. Mammograms are a key component of a womens preventative care. Reproduction without authorization from Blue Shield of California is prohibited. Blue Cross Blue Shield of Massachusetts also offers insurance, pharmacy coverage, and Medicare Plans for seniors; life and disability insurance through Indigo Insurance Services (a wholly owned subsidiary); and insurance for individuals aged 18-26 years. Breast Cancer and Early Detection: What Women Need to Know. Counseling. Most breast cancers are found in women 50 years old and older. Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. Pays cash if you're treated for cancer. Medications covered at 100%: Lovastatin (20 or 40 mg) or Pravastatin (10, 20, 40 or 80 mg). Please review the terms of use and privacy policies of the new site you will be visiting. During your visit, your doctor will determine what tests or health screenings are right for you based on factors such as your age, gender, health status, and health and family history. Among the preventive health benefits for our members, Regence covers mammography at 100 percent for women. Your doctor may order a colonoscopy more frequently than every 10 years. 2 The HPV vaccine (Gardasil) is covered to age 45 per the Food and Drug Administration (FDA) guidelines. Description: Screening for cervical cancer. Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. Routine mammograms are covered by the state health plan at no cost to you. Use this tool to create personalized recommendations for your . All rights reserved. Blue Shield of California 1999 . One its drawbacks is breast tissue can overlap during compression. Forgot User ID? Even if you're feeling fine, scheduling an appointment with your doctor for preventive care services is important. Site Map BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Privacy Policy Learn more about our non-discrimination policy and no-cost services available to you. 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. The cost of many screenings and checkups is covered at 100% with no out of pocket costs for you and those on your plan. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Approve annually starting at age 30; Individuals with known BRCA mutation. For more information, see the Blue Cross and Blue Shield Service Benefit Plan brochures. "When a provider recommends getting screened, it indicates the risks outweigh the benefit and it is deemed to be safe," Dallow said, adding that under the . The scans take detailed X-ray images from many angles. Who Should Get It: Women age 40 and older, Who Should Get It: Age 50 - 80 and high risk due to smoking or other exposure, Who Should Get It: Age 10 - 24 with fair skin, Who Should Get It:Women who have personal or family history of breast, ovarian, tubal or peritoneal cancer or ancestry associated with breast cancer susceptibility, Who Should Get It:High-risk women age 35 and older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, Who Should Get It:Women age 5059 under certain conditions, Who Should Get It:Adults aged 35 to 70 who are overweight or obese; certain women after pregnancy, Who Should Get It: Age 18 and older if at increased risk, Who Should Get It:Women age 65 and older, younger high-risk women, Who Should Get It:Adults aged 40-75 with certain risk factors, Who Should Get It:Pregnant women/women who have delivered a baby recently, Who Should Get It:Pregnant women at high risk for Preeclampsia, Who Should Get It: Pregnant and postpartum women, Who Should Get It: Women planning or capable of pregnancy, 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 who are sexually active or thinking about becoming sexually active. If there is a medical reason you cannot use a generic bowel preparation medication, your doctor should review this. While 3D mammograms show some promise in better health outcomes, there isnt enough research to advocate them over 2D mammograms. Data shows that roughly 30-40% of imaging exams are considered clinically inappropriate or noncontributory. You are only exposed to a small amount of radiation during a mammogram, and studies show that the benefits of mammograms outweigh any risks. Mammograms are one of the best ways to find it early. Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc. DBA Florida Blue. What imaging procedures require prior plan approval? Help Center. Fraud and Abuse For screening examination to detect breast cancer in. Check your Benefit Booklet for details on other preventive care benefits. Annual physical exams and other preventive services are free when you use a Preferred . 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. During your visit, your doctor will perform a clinical breast exam. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Why did Blue Cross NC implement a diagnostic imaging management program? To capture them, the breast is pulled away from the body, compressed and held between two glass plates. Screening for Cervical Cancer Coverage Information. One of the goals of this program is to help contain health care costs. Here are some examples: Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen; Physical therapy, speech therapy and occupational therapy; Weight-reduction procedures How do 3D Mammograms Differ From Standard Ones? While radiation exposure can cause cancer, new technology helps reduce the amount of radiation exposure that comes with a mammogram. Blue Cross Blue Shield Global Core gives Blue Cross and Blue Shield of Vermont members access to their health care benefits wherever they go - across the country and around the world. Your member ID card is your key to using your medical plan benefits. Mammograms are for older women. Fargo, N.D., 58121. January 25, 2016. 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. For more information, view our privacy policy. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the . Originally published 11/16/2015; Revised 2019, 2022, Get News & Updates Directly To Your Inbox. Additionally, the increased use of some high technology imaging procedures creates patient safety concerns from radiation exposure. Forgot User ID? Still, over the past decade, there have been advances in mammogram technology. This new site may be offered by a vendor or an independent third party. If eligible, you must receive genetic counseling and evaluation services before you receive preventive BRCA testing. HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. Limited to a 90 day supply each for two cessation efforts. External link You are leaving this website/app (site). When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. 30 and above: obese. Not all employer groups participate in the diagnostic imaging management program. Issuance of prior approval is not a guarantee of payment. There are also additional guidelines if you're pregnant. According to the American Cancer Society, our state lags behind much of the nation in mammography screenings. Additional Screenings for High-Risk Women Theyll also look for early signs of breast and cervical cancer. You should call the number on the back of your member ID card for more information before you schedule one. Summary of Arkansas Blue Cross Blue Shield and Health Advantage Coverage Polices. Some Blue Cross NCmembers who are employees of religious organizations and their dependents: Talk to your employer or check your benefit booklet to confirm your coverage for these benefits and any limitations. Members must enroll in the multi-call program to qualify for up to 12 weeks of NRT. Achieving this requires that we reduce the number of imaging examinations that do not add diagnostic value for members. Please review the terms of use and privacy policies of the new site you will be visiting. This Bronze standard plan premium covers 60% of costs. 4510 13th Ave. S. Standard 2D mammograms take two pictures of the breast. Standard 2D mammograms take two pictures of the breast. Will this program impact members' ability to receive the tests they need? How do 3D Mammograms Differ From Standard Ones? And that means no copays, coinsurance or payment toward your deductible. But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. Issuance of a prior approval number is not a guarantee of payment. http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. One option is Adobe Reader which has a built-in reader. Find an in-network doctor for preventive care. Approve annually starting at age 30. 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. "Screening" means checking a woman's breasts for cancer before there are signs or symptoms of the disease present. Enrollment in the program is automatic and available to all Blue members. Non-Discrimination Statement and Foreign language Access. listed below will be covered by your plan. By Regence. Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. Your coverage may vary from the types of benefits listed below. This new site may be offered by a vendor or an independent third party. Blue Care Network HMO and POS members. The AIM medical guidelines are publicly available and reviewed regularly by radiologists and practicing physicians of many specialties and updated based on the most current medical evidence. They'll also look for early signs of breast and cervical cancer. Screening for Breast Cancer The goal of the Blue Cross NC Diagnostic Imaging Program is to improve affordability for Blue Cross NC members. The site may also contain non-Medicare related information. The protection of your privacy will be governed by the privacy policy of that site. Most breast cancers are found in women 50 years old and older. Your Florida Blue Medicare health plan includes a mammogram screening every year for women age 40 and over. Cat-scan technology exposes patients to more radiation than an X-rays. No coverage for routine physical examinations. We use cookies on this website to give you the best experience and measure website usage. Our goal is to review diagnostic imaging tests to determine if each test is clinically appropriate for the specific situation. Women between the ages of 40 and 49 should talk to their doctor about when they should start getting mammograms. The average mammogram appointment is just 15 minutes long. As we see trends evolve that may impact patient safety, quality of care or affordability, we must implement solutions that protect our members from these trends.
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