Fall 2010

Changes to Claims Processing of Colonoscopy Benefits

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is continually evaluating our benefit and claim processes to ensure they align with the United States Preventive Services Task Force (USPSTF) recommendations.

As part of this focus, select benefit plans (e.g., certain BlueOptions® and BlueSelect® plans) with a routine colonoscopy benefit (separate from adult wellness) have had 100 percent covered routine colonoscopy services since 2007. However, it was determined that additional procedure and diagnosis codes should be added to routine colonoscopy services to better comply with USPSTF recommendations.

Effective September 23, 2010, claims for benefit plans with separate routine colonoscopy benefits, as well as plans that cover in-network preventive services at 100 percent (as noted in the Availity®1 Health Information Network) must include one of the following procedure and diagnosis codes. In addition, age and frequency limits must be met for the service to be considered a “routine” colonoscopy and be covered under prevention or wellness benefits.

Use the Availity®1 Health Information Network to determine if a plan has a separate routine colonoscopy benefit or preventive services covered at 100 percent. Providers should check the Availity®1 Health Information Network at each member visit, as coverage may change at the group’s renewal to meet Patient Protection and Affordable Care Act requirements.

Note: Claims for other BCBSF plans that include standard coverage for a routine colonoscopy wellness benefit, but have an applicable cost-share, must contain a procedure and diagnosis code. These claims will not have to meet age and frequency limits and will pay based on location of service.

Routine Colonoscopy
Facility and Professional Claims

Alternate Procedure Codes

Routine and High Risk Diagnosis Class

Age Determinant Benefit Limit

45300, 45303, 45305, 45307, 45308, 45317, 45327, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, G0105, G0120, G0121, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45391, 45392, G0106, 45309, 45315, 45320, 45321, 45387, G0104

Routine:
RG & RS V053, V074, V70, V700, V708, V709, V726, V703, V25, V250, V2501, V2502-V2503, V2509, V251, V254, V2540-V2543, V2549, V255, V258-V259, V702, V72, V720, V7241-V7242, V725, V729, V761, V7610, V7611, V7612, V7619, V762, V7651, V7644, V7791, V829, V8281, V765.1, V7641

High Risk:
V1851, V711, V7650, V769, V160

Routine:

  • Over 50 years of age, One every 10 years

  • High-Risk: Regardless of age; One every two years

  • Routine under age 50 deny

Note: Does not apply to 00810

Verifying Colonoscopy Benefits

Verifying eligibility and benefits (E&B) is easy using the Availity®1 Health Information Network. Simply log on to the Availity Health Information Network and follow the steps below:

Note: You must be a registered Availity user to access this information. To register, visit www.availity.com.

  1. Select Eligibility & Benefits from the options menu, then select Eligibility & Benefits Inquiry.

  2. Complete the following data fields:

    • Payer

    • Organization: Select from the drop down.

    • Express Entry - Provider (Optional): To set up Express Entry, see the Additional Information section.

    • NPI: Use the individual provider’s National Provider Identifier (NPI) or Payer Assigned Provider ID. Do not use the group NPI or BCBSF number.

    • As of Date: Defaults to current date

    • Type of Benefit Requested: Select Professional (Physician) Visit — Office from the drop-down menu. For additional information, select Health Benefit Plan Coverage from the View More drop-down menu.

  3. After selecting the appropriate type of benefits, complete the following fields on the Eligibility & Benefits Inquiry page.

    • Patient ID

    • Patient Last Name

    • Patient First Name

    • Date of Birth

    • Patient’s Relationship to Subscriber

  4. Click Submit.

  5. View Results screen(s).

The Results screen will display the applicable benefits associated with the benefit type you selected.

Note: If a member has a plan with a separate routine colonoscopy benefit, a separate line in the benefits results will indicate Routine Colonoscopy covered at 100 percent. If the member has routine colonoscopy covered at 100 percent under preventive services, results will indicate Routine Adult & Child Preventive Services, Wellness Services, and Immunizations covered at 100 percent in-network.

1 Availity, LLC, is a multi-payer joint venture company. For more information or to register, visit Availity's website at www.availity.com.