Issuance of prior approval is not a guarantee of payment. Most PDF readers are a free download. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Women ages 40 and older can receive a mammogram (four views) each calendar year. Regular mammograms improve survival rates by 35% in women over 50. 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. Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc. DBA Florida Blue. The cost of many screenings and checkups is covered at 100% with no out of pocket costs for you and those on your plan. AIM has a track record of successful experience working with many providers and other Blue Cross and Blue Shield plans across the country. Nothing to fear: Its normal to feel scared before any medical procedure, but theres nothing to worry about! Fargo, N.D., 58121. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. 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. Select Your Gender. Thanks in part to preventive screenings, there are approximately 2.8 million breast cancer survivors in the U.S. as of 2016. 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. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. How should providers request prior approval? should confirm that a prior approval number has been issued. Pays in addition to your other coverages. Breast cancer is the most widely found cancer in U.S. women, next to skin cancer. Check out the changes and updates to our plan in 2023. Am I eligible for these benefits at 100%? . It often forms in the tubes that carry milk to the nipple (ducts) and in glands that make milk (lobules). Preventive care includes routine well exams, screenings and immunization intended to prevent or avoid illness or other health problems. Approve annually starting at age 30. 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 . You should get screenings every one or two years, depending on your doctor's advice. Our goal is to review diagnostic imaging tests to determine if each test is clinically appropriate for the specific situation. Connect Community - Blue Cross and Blue Shield of Illinois, Radiation treatments to the breast or chest area. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. 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. Breast Cancer Mammography Screening Age 35-39 . They'll also look for early signs of breast and cervical cancer. 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. 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. For more information, view our privacy policy. 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. This is especially important for women who have dense breast tissue. Inscribirse ahora! 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.) "Screening" means checking a woman's breasts for cancer before there are signs or symptoms of the disease present. These benefits are available for members of non-grandfathered individual health insurance plans. While radiation exposure can cause cancer, new technology helps reduce the amount of radiation exposure that comes with a mammogram. Forgot Password? For more information, view our privacy policy. *Applicable Wellness Screenings: $50 benefit paid one time per year, per insured (age 18 and over) for breast ultrasound, breast MRI, mammograms, CA 15-3 . Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Yes. You have coverage from another insurance plan in addition to your Blue Cross and Blue Shield of Nebraska coverage. Tissue doesnt overlap. Register Now, Ancillary and Specialty Benefits for Employees. 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. There are significant concerns about patient safety involved in the increased exposure to radiation due to diagnostic imaging procedures. Blue Cross NC is very aware of the concerns about self-referral. . 140 0 obj <>stream Do practicing North Carolina physicians have input into the program? Fortunately, only about 1 in 400 people have a BRCA gene. Will this program impact members' ability to receive the tests they need? The cost estimate changed prior to your care. Still, over the past decade, there have been advances in mammogram technology. 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. Who reviews requests for diagnostic imaging prior approval? For women age 30-65. Issuance of a prior approval number is not a guarantee of payment. The site may also contain non-Medicare related information. They can help detect breast cancer up to three years before it can be felt. Returning Shopper? About 10% of patients who receive routine mammograms get called back for another look. Healthy tissue may appear suspicious and cancerous tissue can be masked. Select a Region: Please Select One DVEST1 DV9ST1 DV8ST1 DV5ST1 DV4ST1 DV1ST1 DVPST1 DVOST1 DVMST1 DVJST1 DVHST1 DVGST1 DVFST1 DVEST1 DVDST1 DVCST1 LOEST1 Scroll down to see some common services that may or may not be covered during a preventive care visit. 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. Learn more about our other insurance plans and Medicare plans, or contact a sales . Routine physical exams where your doctor reviews the following: This exam is prevention focused, not problem focused. Understand the difference between preventive and diagnostic. One option is Adobe Reader which has a built-in screen reader. BlueCross BlueShield of South Carolina. Blue Cross and Blue Shield Federal Employee Program Yesterday at 1:00 PM Simple yet warm, this customizable sheet pan lemon-roasted fish . Learn more aboutmammogram screeningsin this video. Did you know that one in eight women will develop invasive breast cancer at some point in her life? HMO Scope of Benefits Section . Most Florida Blue plans cover annual screening mammograms for women age 40 and older for as low as a $0 copay. Your doctor can help determine your risk level and what steps you should take. Regence supports women's preventive breast health. 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. Currently, under the Patient Protection and Affordable Care Act Annual Checkups and certain preventive . Ordering physicians for Blue Cross NC members must obtain prior approval prior to scheduling an imaging exam for outpatient diagnostic, non-emergent services. All Rights Reserved. Routine mammograms are covered by the state health plan at no cost to you. Accessibility Ordering physicians may also contact the AIM physician reviewer at any time during the authorization process. Page 2 of 33. time of service to determine coverage or non -coverage of these services as it applies to an individual member. Annually about 220,000 women are diagnosed with breast cancer. As always, be sure to check your specific plan coverage and see an in-network provider. Colorectal Cancer . Examples of these services include: Initial evaluation. There has been an error with your submission. Your doctor may order a colonoscopy more frequently than every 10 years. Coverage Information. Mental Health Services. Reproduction without authorization from Blue Shield of California is prohibited. Insurance. Heres everything you need to know about it. Linked Apps. Download the BCBSIL App. Breast tomosynthesis is an . This new site may be offered by a vendor or an independent third party. However, sometimes tests are ordered and are not clinically appropriate. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. 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. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Blue Shield of California 1999 . A Pap test every 3 years or. Be sure you're taking full advantage of your coverage. Your Florida Blue Medicare health plan includes a mammogram screening every year for women age 40 and over. Please review the terms of use and privacy policies of the new site you will be visiting. Usage Agreement Fraud and Abuse Learn more about our non-discrimination policy and no-cost services available to you. 1 If you have gotten one dose of Zostavax vaccine for shingles, you should also get the two doses of Shingrix vaccine. 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. Disponible nicamente en ingls. What are the goals of the diagnostic imaging management program? 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. mammogram for women between ages 35-39. Some buy into dangerous myths about breast cancer. Members must enroll in the multi-call program to qualify for up to 12 weeks of NRT. Genetic counseling and evaluation can help determine if youve inherited a BRCA mutation. A high BMI can be a warning sign for potential health problems. Health plans are offered by Blue Shield of California. Blue Cross and Blue Shield of Louisiana joins other healthcare organizations in reminding Louisianians how important it is to know your personal health risks and ask your doctor about screening. Talk to your doctor to find out which of these you should have based on your health. Find an in-network doctor for preventive care. You will be required to pay the plan's physician office copayment or coinsurance. We have an obligation to our members to provide quality care at an affordable price. BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Additional mammograms may require cost sharing. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. 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. %PDF-1.5 % Additionally, we cover computer-assisted detection for those women who seek an extra level of screening for breast cancer. What imaging procedures require prior plan approval? 2023 Blue Cross and Blue Shield of North Carolina. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Coverage that is supplemental to Medicare but with no member cost Yes, as of September 1, 2010, all Blue Medicare HMO and Blue Medicare PPO members participate in the program. Mammograms are for older women. When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. How long is an authorization of a diagnostic imaging procedure valid? This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. Here's how to interpret your BMI: Below 18.5: underweight. There is an appeals process in place for unfavorable determinations. Screening can help find breast cancer early, when it is easier to treat. Standard 2D mammograms take two pictures of the breast. If physicians have questions about the Blue Cross NC diagnostic imaging management program, they should contact their local Network Management representatives. Life-Saving: Cancer detection is the key to early treatment and better outcomes. Note: The Illinois Insurance Code requires all health insurers to provide coverage for mammography, including: one baseline study age 35-39, and an annual mammogram for women 40 and older. Dental, Life and Disability are offered by Florida Combined Life . We cover mental health services for transgender and gender-diverse members, whether or not you have a mental health diagnosis. . "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 . There are also additional guidelines if you're pregnant. This screening is no cost to you. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. This information is a reference tool and does not guarantee payment of any claims. To capture them, the breast is pulled away from the body, compressed and held between two glass plates. Find A Doctor Or Hospital In Your Network. Dynamic contrast material-enhanced MRI may be used to monitor response of a tumor to neoadjuvant chemotherapy used to shrink the tumor before surgery. You should call the number on the back of your member ID card for more information before you schedule one. - 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. Which health plans does the program apply to? Your member ID card is your key to using your medical plan benefits. BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Most basis mammogram screenings are covered by your health plan. Easy: Keeping up with your screenings is an important task, even in your busy life. Click on a service to see any limits or exclusions. BSC6.07 Digital Breast Tomosynthesis. What places or settings of treatment are affected? The good news is that mammograms can catch cancer early, when its easiest to treat, even if you dont have any symptoms. Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. Forgot User ID? Did you know preventive health measures and screenings can prevent 85% of illness and disease, and are covered at no cost for many 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. The goal of the diagnostic imaging program is to improve affordability of health care to Blue Cross NC members. Please enter a valid date of birth (MM/DD/YYYY), 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, PDF File is in portable document format (PDF). Necesita su ID de usuario? Assessing Your Risk How do 3D Mammograms Differ From Standard Ones? Pays cash if you're treated for cancer. %%EOF Blue Care Network HMO and POS members. Talking with your healthcare provider about the . For screening examination to detect breast cancer in. "Breast cancer is the most common cancer in American women, but men can also develop breast cancer," said Blue Cross and Blue Shield of . Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. For example, women who have a family history of breast, cervical or ovarian cancer can be tested for the BRCA1 or BRCA2 genes. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. The policies were effective for diagnostic imaging services performed on or after February 15, 2007 for Blue Cross NC commercial plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. No lump, no cancer. Olvido su contrasea? Bacteriuria screening for pregnant women. For most women, mammogram technology is still considered the best way to detect breast abnormalities and cancers early. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Out of network billing can lead to unexpected charges. Breast cancer mammography screenings for women over age 40; Colorectal cancer screening for adults over age 45; . Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. 2021 plans will be available for purchase beginning on November 1, 2020. 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. Frequency: In women age 21-29 with cervial cytology (pap test) every 3 years. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Most PDF readers are a free download. Coverage is subject to the specific terms of the member's benefit plan. We use cookies on this website to give you the best experience and measure website usage. Originally published 11/16/2015; Revised 2019, 2022, Get News & Updates Directly To Your Inbox. Use the subsidy calculator to enter your own . endstream endobj startxref We apologize for any inconvenience. It happens in both men and women, but breast cancer in men is not common. As an example, women get regular mammograms at no cost to them as a preventive screening. Some preventive care services require that you meet . "To put it in perspective, the dose of radiation is lower than that of a chest x-ray," Mehta said. NRT through the pharmacy benefit is available only with a prescription. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. SOURCES: Another Reason to Get Moving: Exercise Can Help Lower Cancer Risk. Barium enema is a covered service but not at 100% so you may have out of pocket costs. 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 . However, some services like 3D imaging or ultrasounds may not be fully covered the same way. Cost estimates are based only on the coverage you have with us. The diagnostic imaging management program impact is low; why did Blue Cross NC implement it? Women ages 35-39 can receive one baseline mammogram (four views). Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. 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. All premiums listed represent coverage for dependents up to age 26. Tobacco and alcohol use evaluations. Provider consultation prior to the colonoscopy procedure is covered at 100%. 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. Check your Benefit Booklet for details on other preventive care benefits. A normally functioning BRCA gene helps prevent cancer by suppressing tumor growth. Anemia screening for pregnant women. Who Should Get It: Women age 21 - 65. 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. Additional Screenings for High-Risk Women Is the program focused mainly on saving money? . Make sure to get all the screenings and vaccines recommended for your age and gender. Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography . For transgendered individuals, you have access to medically appropriate preventive services. You must also receive prior approval from us. BRCA is an abbreviation for the BReast CAncer gene, which is an inherited trait. Find your ideal accommodation from hundreds of great deals and save with www.trivago.com Should a member request Coverage is subject to the specific terms of the member's benefit plan. Combined together, the X-rays create a three-dimensional picture of each breast. All rights reserved. They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. It is important to note that these services are free only when delivered by a doctor or other . Providers can find complete instructions on how to request prior approval outlined on the diagnostic imaging procedures page. Women ages 40 and older can receive a mammogram (four views) each calendar year. 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. Preventive Care. The average mammogram appointment is just 15 minutes long. This is very important in clinical decision making as alternative therapies may be selected based upon the results obtained from the MRI. $300 inpatient benefits. Approve annually starting at age 30; Individuals not yet tested for BRCA gene, but with known BRCA mutation in first degree relative. Some providers charge more, and some offer an uninsured discount. Copyright 2023 Health Care Service Corporation. Hysterectomies are not performed solely for sterilization so are not covered as preventive. However, your group may decide to delay the effective date for coverage until your group's plan . If you have a higher risk for breast cancer, talk to your doctor about screening, no matter how old you are. 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. 0 We use cookies on this website to give you the best experience and measure website usage. NRT through QuitlineNC is available without a prescription. 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. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. Depression screenings.