Health Plan - Preventive

What is preventive care?
Routine or preventive care is undertaken without any indication that you are sick. You might want to establish a baseline (a physical), screen for diseases (a mammogram), or get an immunization to offset the chance of catching something (a flu shot). Routine care is covered at 100 percent of allowable charges under the preventive care provision. Premera has provided a list of essential preventive health services for adults and children.

What is diagnostic care?
You seek diagnostic care because you are exhibiting symptoms that point to a health problem—a persistent cough, pain, trouble breathing or other difficulties that indicate something is wrong. If you are seeking medical care because you want to know what is causing a problem or to monitor an ongoing condition, that is diagnostic care. and is not covered under the preventive benefit. This type of care is covered under the medical plan and is subject to a deductible and copayment.

If I go in to monitor a long-term health care condition, will that be covered under preventive care?
No, even though you may not be exhibiting symptoms at that time. Preventive care only applies to tests and procedures that are used to establish your health status or prevent a health problem. Care for existing health conditions are covered under the medical plan.

How do I know if my procedures will be processed under the preventive benefit?
It is important that your physician be informed up front that you are seeking preventive care. Your physician must code your claim as routine in order to be processed as a preventive benefit. Also, some procedures do not fall under routine care, check with your physician to see if the procedure you want is considered a routine or preventive measure.


I have chronic health care conditions; can I ever use the preventive benefit?
Anyone can request a routine physical or screening as part of this benefit, but you need to be sure that your physician understands that this is a routine office visit. Your physician may ask about ongoing health problems as long as the entire visit is treated as a routine physical, not as maintenance of your chronic condition. In any visit in which diagnostic care is performed, including monitoring a long-term health care condition, the diagnostic code will take precedence making the claim subject to the medical plan.

What if my physician wants to run some lab tests at the same time as my routine physical?
Your office visit may still be treated as a routine physical even if the lab tests are diagnostic as long as the lab tests are submitted separately. The office visit will be paid under the preventive benefit and the lab tests will be paid under the medical plan.

I went in for a routine physical and routine lab tests but the lab tests found something wrong; how will the follow-up visits be processed?
The first office visit and related lab work were routine and will be covered under the preventive benefit. However, all follow-up visits will be used to diagnose the findings of the lab work so they are paid through the regular medical plan coinsurance.

What if my routine office visit is miscoded?
Your physician may resubmit your insurance claim with the office notes from that visit. If the office notes support that your visit was for routine care only, the claim will be reprocessed under the preventive benefit. If the office notes contain evidence of diagnostic care (care related to an illness or symptoms of an illness), your claim will not be reprocessed.

What happens if my office visit includes both routine and diagnostic care?
Every office visit has an overriding office code attached to it; a visit with both routine and diagnostic codes will be processed as a diagnostic visit, which is subject to the deductible and regular coinsurance. You will need to have a separate office visit for preventive care.

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