Linked Apps. "To put it in perspective, the dose of radiation is lower than that of a chest x . 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. 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. 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. For screening examination to detect breast cancer in. Did you know that one in eight women will develop invasive breast cancer at some point in her life? . Your member ID card is your key to using your medical plan benefits. Issuance of a prior approval number is not a guarantee of payment. Side-to-side and top-to-bottom images are made. 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. This new site may be offered by a vendor or an independent third party. Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. hb```,z@ (Mf`X b`Fe~F9}mS6.awa`\V_RQ g-e0 Usage Agreement Coverage is subject to the specific terms of the member's benefit plan. Bronze Standard - Individual & Family Health Plans 2021 - BCBSWNY All women 40 or older should ask their doctor about when to start getting mammograms and how often theyre needed. 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. 122 0 obj <>/Filter/FlateDecode/ID[<13345823F9F84C49978F51E9E4B0DEB3><85AA0C7815CFFF46BE97C496C3A4895B>]/Index[104 37]/Info 103 0 R/Length 89/Prev 75360/Root 105 0 R/Size 141/Type/XRef/W[1 2 1]>>stream Your Guide to Women's Preventive Care - FEP Blue Learn the facts, then schedule an appointment today! Blue Shield of California 1999 . Page 2 of 33. time of service to determine coverage or non -coverage of these services as it applies to an individual member. Still, over the past decade, there have been advances in mammogram technology. Side-to-side and top-to-bottom images . What imaging procedures require prior plan approval? 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. If so, it should not impact the ability of members to receive these tests. 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. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL Most Florida Blue plans cover annual screening mammograms for women age 40 and older for as low as a $0 copay. Site Map Preventive Service Benefits - Bcbsal.org The goal of the Blue Cross NC Diagnostic Imaging Program is to improve affordability for Blue Cross NC members. Women between the ages of 40 and 49 should talk to their doctor about when they should start getting mammograms. PDF Preventive care services: Get the most out of your Blue Cross plan - BCBSM Annually about 220,000 women are diagnosed with breast cancer. 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. recipe is no mess, no fuss and all flavor. Enrollment in the program is automatic and available to all Blue members. There are many easy-to-use BMI calculators online, such as this example from the Centers for Disease Control and Prevention.*. Texas insurers to cover advanced breast cancer screenings 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. 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. Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. 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 . Cost of a Mammogram - 2023 Healthcare Costs - CostHelper 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. Mammograms 101 - Anthem So why do so many women put off their mammograms? Blue Cross and Blue Shield Association. 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. 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. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. You should call the number on the back of your member ID card for more information before you schedule one. Health plans are offered by Blue Shield of California. 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. 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. What clinical criteria does AIM use to determine if a procedure will be approved? All women need to be informed by their healthcare provider about the best screening options for them. As always, be sure to check your specific plan coverage and see an in-network provider. If your Summary of Benefits section of your Benefit Booklet contains PREVENTIVE CARE covered under federal law, then you have these benefits at no charge IN-NETWORK. 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. 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. Screening for Cervical Cancer The U.S. Preventive Services Task Force currently recognizes both 2D and 3D mammography as equally acceptable screening methods. Breast cancer mammography screenings for women over age 40; Colorectal cancer screening for adults over age 45; . Others have a false sense of . Breast cancer mammography (at least one baseline mammogram during the 5-year period a member is age 35 through 39 and one mammogram for each member in each calendar year for a member age 40 or older) . This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. How long is an authorization of a diagnostic imaging procedure valid? 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. Place of service exclusion: Sterilization coverage applies to all places of service, with the exception of the Emergency Room. Talk to your doctor to find out which of these you should have based on your health. Check out the changes and updates to our plan in 2023. These benefits are available for members of non-grandfathered individual health insurance plans. But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. Usage Agreement Hospitals and freestanding imaging centers that perform the imaging services cannot obtain the approval. For women age 30-65. Diagnostic mammograms more frequently than once a year, if medically necessary. Screening for depression in postpartum women. It's important to note that your provider has the right to code and bill services according to his or her viewpoint. SOURCES: Cost estimates are based only on the coverage you have with us. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. If you had a polyps removed during a previous preventive screening colonoscopy, future colonoscopies will be covered but may not be considered preventive so you may have out of pocket costs. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. PDF Anthem Blue Cross and Blue Shield - Portal.ct.gov No. During this visit, your doctor examines your overall health. While radiation exposure can cause cancer, new technology helps reduce the amount of radiation exposure that comes with a mammogram. Women ages 35-39 can receive one baseline mammogram(four views). Pays in addition to your other coverages. Check your Benefit Booklet for details on other preventive care benefits. Depression screenings. $100 outpatient benefits. 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.) 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? You have coverage from another insurance plan in addition to your Blue Cross and Blue Shield of Nebraska coverage. Mammograms are one of the best ways to find it early. 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. To learn if your patient's plan requires prior approval for these services, please reference the diagnostic imaging procedures page. Hysterectomies are not performed solely for sterilization so are not covered as preventive. According to the American Cancer Society, our state lags behind much of the nation in mammography screenings. You are viewing estimated values for an individual. 30 and above: obese. By using X-rays, they create two-dimensional images of the breast to spot suspicious tissue that may be cancerous. Download the BCBSIL App. In fact, we rank 32nd out of 50 states. What is 3D Mammography? | Blue Cross Blue Shield of Illinois Returning Shopper? endstream endobj startxref 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. Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. Who Should Get It: Women age 21 - 65. Tissue doesnt overlap. Not all participating DME vendors carry breast pumps. One of the goals of this program is to help contain health care costs. By slowing this growth and containing costs through a proactive diagnostic imaging management program, we anticipate costs savings over time. Assessing Your Risk 2020. . 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. Its important for adult women to have annual wellness exams after the age of 21. Psychotherapy. Regular mammograms improve survival rates by, Thanks in part to preventive screenings, there are approximately, The average mammogram appointment is just. Coverage - a BCBSMA news service - Blue Cross Blue Shield MA MediaRoom For that reason, benefits for preventive BRCA testing are available for members with a family history of certain cancers. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the . We can send you an email with information on our health care plans. Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. 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. Fraud and Abuse HMO Scope of Benefits Section . The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the President in March 2010. . Some sites may require you to agree to their terms of use and privacy policy. No. Breast cancer is the most common type of cancer in women. It may also be used to depict residual disease after neoadjuvant chemotherapy. Support Transgender services | Blue Cross Blue Shield of Massachusetts If something is found in a preventive screening mammogram, the screening is still at no cost to the member. Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. 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. Access Your Payment Options. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the . Mammograms are for older women. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Approve annually starting at age 30; Individuals with known BRCA mutation. Mammograms: Early detection saves lives | Coverage - Blue Cross Blue . Preventive Health Care Plans & Guidelines | Anthem.com 2021 plans will be available for purchase beginning on November 1, 2020. Frequently Asked Questions: Mammograms - Blue Cross Blue Shield of This is especially important for women who have dense breast tissue. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. If physicians have questions about the Blue Cross NC diagnostic imaging management program, they should contact their local Network Management representatives. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Linked Apps. Use the subsidy calculator to enter your own . Your doctor will collect a sample of cells from your cervix to test for any abnormal or precancerous cells. Fraud and Abuse 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. Breast Screening Benefit "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography . Help Center. HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. However, if her doctor schedules a follow up mammogram six months later to re-examine that change, it would be used to diagnose a symptom, so it . MRI of the breast is a useful tool for the detection and characterization of breast disease, assessment of local extent of disease, evaluation of treatment response, and guidance for biopsy and localization. For more information, see the Blue Cross and Blue Shield Service Benefit Plan brochures. Side-to-side and top-to-bottom images . Talking with your healthcare provider about the . Among the preventive health benefits for our members, Regence covers mammography at 100 percent for women. If you have a higher risk for breast cancer, talk to your doctor about screening, no matter how old you are. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. Scenario 1: Brand Truvada, Viread, or Descovy may be made available if you are clinically unable to use generic Truvada. 104 0 obj <> endobj PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL Insurance. 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. Check out the changes and updates to our plan in 2023. Coverage Policy Manual - Arkansas Blue Cross and Blue Shield 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. We use cookies on this website to give you the best experience and measure website usage. Negotiated rates with providers can change, therefore, changing the estimate. Summary of Preventive and Contraceptive Services - CareFirst Important Information | Services that need approval | bcbsm.com Fargo, N.D., 58121. Use this tool to create personalized recommendations for your . When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. As a result, 3D mammograms lower the number of false alarms. Some women have a higher risk of developing cancer than other women. 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). Medications covered at 100%: Lovastatin (20 or 40 mg) or Pravastatin (10, 20, 40 or 80 mg). Breast Cancer Mammography Screening Age 35-39 . Dynamic contrast material-enhanced MRI may be used to monitor response of a tumor to neoadjuvant chemotherapy used to shrink the tumor before surgery. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. "To put it in perspective, the dose of radiation is lower than that of a chest x-ray," Mehta said.