Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Preventive care aims to prevent or reduce disease risk factors and promote early detection of disease or precursor states. Medical services and supplies required for preventive care are to be provided to all members as directed by the primary care physician (PCP) or designee.
Preventive care service guidelines include:
- Routine pediatric and adult examinations and health screenings, newborn hospital visits, counseling anticipatory guidance, developmental and behavioral assessment, screening diagnostic tests, and laboratory services
- Routine pediatric immunizations recommended jointly by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP), and the American Academy of Family Physicians (AAFP)
- Routine adult immunizations recommended by ACIP
Health Net PCPs should consult the Guide to Clinical Preventive Services, a report of the U.S. Preventive Services Task Force (USPSTF), as the minimum acceptable standard for adult health services. Current USPSTF guidelines can be found on the Agency for Healthcare Research and Quality (AHRQ) website.
Covered CPT Codes
Most preventive services are covered by the following CPT codes:
- 99381-99384 (physical examination for new patients under age 18).
- 99203-99205 (physical examination for new patients ages 18 and over).
- 99391-99394 (physical examination for established patients under age 18).
- 99203-99205 (physical examination for established patients ages 18 and over).
The primary care physician (PCP) is responsible for:
- Providing an initial health appointment (IHA), which includes an age-appropriate history and physical examination within 120 calendar days after the member's date of enrollment.
- Completing ongoing health assessments as indicated in the periodicity table. Adult and senior assessments are completed every three to five years.
- Notifying members of periodic or clinically indicated appointments.
- Documenting assessment findings, treatment, recommendations, and follow-up in the member's medical record.
- Providing follow-up care, laboratory evaluation and specialty care if a medical condition warranting further care is found at the time of routine assessment.
- Coordinating care with specialists, including providing adequate clinical information to specialists to whom a member was referred for additional services.
- Making appointments for required assessments.
- Documenting missed or broken appointments in the member's medical record and following up with the member according to the procedure for missed or broken appointments.