The good news is that mammograms can catch cancer early, when its easiest to treat, even if you dont have any symptoms. Approve annually starting at age 30; Individuals with known BRCA mutation. No family history, no risk. Inscribirse ahora! Fraud and Abuse Typical costs: For an uninsured patient, typical full-price cost of a mammogram ranges from $80 to $120 or more, with an average of about $102, according to Blue Cross Blue Shield of North Carolina. For this reason, 2D mammograms can sometimes produce inaccurate findings. They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. 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. Inscribirse ahora! Check your Benefit Booklet for details on other preventive care benefits. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. Fraud and Abuse 1 If you have gotten one dose of Zostavax vaccine for shingles, you should also get the two doses of Shingrix vaccine. (MAMMOGRAPHY) (Coverage Policy 2011018) USPSTF Recommendation. See your doctor andrefer to the CDCs posted schedule of immunizations for more information. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. Covered: Getting screened wont break the bank. Check out the changes and updates to our plan in 2023. The Diagnostic Imaging Management Advisory Group is asked to help develop future phases of the diagnostic imaging program, including addressing over-utilization by self-referring physicians as necessary. As North Dakotans, we can do better in checking for breast cancer. Your coverage information in the palm of your hand. Description: clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. Theyre covered, lifesaving and nothing to fear. Learn more aboutmammogram screeningsin this video. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. If you don't see your insurance plan listed, please contact our Insurance Hotline at 469-398-4099 or email us at insuranceinfo@solismammo.com. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Theyll also look for early signs of breast and cervical cancer. Out of network billing can lead to unexpected charges. Frequency: In women age 21-29 with cervial cytology (pap test) every 3 years. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. Who Should Get It: Sexually active women 24 years or younger and in women 25 years or older who are at increased risk of infection, Who Should Get It:Women at high risk of infection or pregnant women, Who Should Get It:Persons at high risk of acquiring HIV, Who Should Get It:Women to age 65 or older if at increased risk, Who Should Get It:Women at high risk of infection and pregnant women, Who Should Get It:Age 18 and older, including pregnant women, Who Should Get It:Women of reproductive age, Who Should Get It:Age 18 and older; when pregnant, Who Should Get It:Women, dependent children up to age 26, pregnant women, Who Should Get It:Women aged 40 to 60 years with normal or overweight body mass index (BMI) of 18.5 - 29.9. Fargo, N.D., 58121. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Routine health checkups. Copyright 2023 Health Care Service Corporation. Did you know that one in eight women will develop invasive breast cancer at some point in her life? Summary of Arkansas Blue Cross Blue Shield and Health Advantage Coverage Polices. No prescription medication or NRT limit when received via pharmacy benefit, Tetanus-Diphtheria/Tetanus-Diphtheria Acellular Pertussis (Tdap). Blue Shield of California is an independent member of the Blue Shield Association. Mammograms use very small doses of radiation and the risk of harm is very low. Screening for Cervical Cancer The U.S. Preventive Services Task Force currently recognizes both 2D and 3D mammography as equally acceptable screening methods. Life-Saving: Cancer detection is the key to early treatment and better outcomes. However, your group may decide to delay the effective date for coverage until your group's plan . Your doctor will help you decide what schedule makes the most sense for you. By Regence. During this visit, your doctor examines your overall health. Blue Shield of California 1999 . Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. 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. Be sure you're taking full advantage of your coverage. Heres everything you need to know about it. Necesita su ID de usuario? Telephonic counseling available by calling QuitlineNC at 844-8NCQUIT. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Issuance of a prior approval number is not a guarantee of payment. "To put it in perspective, the dose of radiation is lower than that of a chest x-ray," Mehta said. Usage Agreement Coverage that is supplemental to Medicare but with no member cost Some state or federal mandates [e.g., Federal Employee Program (FEP)] prohibits plans from All premiums listed represent coverage for dependents up to age 26. External link You are leaving this website/app (site). We believe that it is critical to carefully examine the appropriate use of outpatient, nonemergency diagnostic imaging procedures to make sure that the benefit of the procedure outweighs the risk. Coverage Information. Most breast cancers are found in women 50 years old and older. Depression screenings. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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. Please utilize the checklist below as a guideline to ensure you have all the necessary information before requesting prior approval: For complex cases, more information may be necessary, including: The diagnostic imaging management process is based upon AIM clinical practice guidelines, developed from consensus opinion in medical practice and integration of medical information from multiple sources, including: The prior approval number will be valid for 30 days from the date issued - not the date of service requested. Servicing providers (hospitals, freestanding imaging centers, etc.) "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 . Genetic counseling and evaluation can help determine if youve inherited a BRCA mutation. Side-to-side and top-to-bottom images . However, some services like 3D imaging or ultrasounds may not be fully covered the same way. %PDF-1.5 % Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. All Rights Reserved. Understand the difference between preventive and diagnostic. 2021 plans will be available for purchase beginning on November 1, 2020. A high BMI can be a warning sign for potential health problems. 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. 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. No lump, no cancer. As a result, 3D mammograms lower the number of false alarms. If so, it should not impact the ability of members to receive these tests. Generally, practicing consistently with national evidence-based guidelines is expected to reduce errors and liability. All women 40 or older should ask their doctor about when to start getting mammograms and how often theyre needed. List of all medications that are covered at 100% onall formularies. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. Heres a deeper dive on the potential benefits and risks of a 3D mammogram. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. If you have a higher risk for breast cancer, talk to your doctor about screening, no matter how old you are. To view this file, you may need to install a PDF reader program. All rights reserved. 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. During this visit, your doctor examines your overall health. Mammograms are one of the best ways to find it early. Blue Cross and Blue Shield Service Benefit Plan brochures, https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815. Additional Screenings for High-Risk Women 30 and above: obese. Approve annually starting at age 30. Take advantage of preventive care and stop problems before they get serious. Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023, http://www.breastcancer.org/symptoms/understand_bc/statistics, https://www.anthem.com/health-insurance/health-care-reform-resources/reform-law-detail/more-womens-preventive-care-covered?reformlaw=l1019, http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. Enroll Now. 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 . Health Plans for Individuals and Families, Get a Quote for Individual and Family Plans, Non-Discrimination Policy and Accessibility Services. Site Map 140 0 obj <>stream Are you going to reimburse providers for the savings Blue Cross NC will incur? We use cookies on this website to give you the best experience and measure website usage. AIM has a track record of successful experience working with many providers and other Blue Cross and Blue Shield plans across the country. 2 The HPV vaccine (Gardasil) is covered to age 45 per the Food and Drug Administration (FDA) guidelines. Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. 3D mammograms may be covered by your health plan. Mammograms are the best way to screen for breast cancer and can detect cancer up to three years before other signs and symptoms appear. Will the diagnostic imaging management program increase the risk of malpractice? 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. Your coverage may vary from the types of benefits listed below. This new site may be offered by a vendor or an independent third party. Screening for depression in postpartum women. To capture them, the breast is pulled away from the body, compressed and held between two glass plates. Find an in-network doctor for preventive care. Linked Apps. Anemia screening for pregnant women. A Pap test and high-risk human papillomavirus (hrHPV) test every 5 years or. Blue Cross NC will be the fourth company to implement a diagnostic imaging program in North Carolina. Recommended repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 2428 weeks gestation unless the biological father is known to be Rh (D)-negative, Anesthesia services will pay at 100% only for sterilization, Certain services for contraceptive device insertion and removal, such as ultrasounds to confirm IUD placement, will pay at 100%, Pregnancy tests prior to the initiation of contraceptive will pay at 100%. Regence supports women's preventive breast health. However, sometimes tests are ordered and are not clinically appropriate. For transgendered individuals, you have access to medically appropriate preventive services. Limited to a 90 day supply each for two cessation efforts. 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. January 25, 2016. 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? 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. 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). endstream endobj 105 0 obj <. Technical Information Of the 4 million women age 40 to 65 in Texas, 2.6 million . Healthy tissue may appear suspicious and cancerous tissue can be masked. The site may also contain non-Medicare related information. Your doctor can help you choose a facility thats convenient for you. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. MRI findings should be correlated with clinical history, physical examination results, and the results of mammography and any other prior breast imaging. Most basis mammogram screenings are covered by your health plan. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the . Combined together, the X-rays create a three-dimensional picture of each breast. This is especially important for women who have dense breast tissue. This happens by feeling breast tissue for any lumps or abnormal areas. Some providers charge more, and some offer an uninsured discount. 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. But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. Place of service exclusion: Sterilization coverage applies to all places of service, with the exception of the Emergency Room. Why did Blue Cross NC implement a diagnostic imaging management program? Thanks in part to preventive screenings, there are approximately 2.8 million breast cancer survivors in the U.S. as of 2016. Technical Information It happens in both men and women, but breast cancer in men is not common. Among the preventive health benefits for our members, Regence covers mammography at 100 percent for women. "To put it in perspective, the dose of radiation is lower than that of a chest x . Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. You are only exposed to a small amount of radiation during a mammogram, and studies show that the benefits of mammograms outweigh any risks. listed below will be covered by your plan. Routine mammograms are covered by the state health plan at no cost to you. 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. Check out the changes and updates to our plan in 2023. Who Should Get It: Women age 40 and older, Who Should Get It: Age 50 - 80 and high risk due to smoking or other exposure, Who Should Get It: Age 10 - 24 with fair skin, Who Should Get It:Women who have personal or family history of breast, ovarian, tubal or peritoneal cancer or ancestry associated with breast cancer susceptibility, Who Should Get It:High-risk women age 35 and older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, Who Should Get It:Women age 5059 under certain conditions, Who Should Get It:Adults aged 35 to 70 who are overweight or obese; certain women after pregnancy, Who Should Get It: Age 18 and older if at increased risk, Who Should Get It:Women age 65 and older, younger high-risk women, Who Should Get It:Adults aged 40-75 with certain risk factors, Who Should Get It:Pregnant women/women who have delivered a baby recently, Who Should Get It:Pregnant women at high risk for Preeclampsia, Who Should Get It: Pregnant and postpartum women, Who Should Get It: Women planning or capable of pregnancy, Who Should Get It:Sexually active women 24 years or younger and in women 25 years or older who are at increased risk of infection, Who Should Get It:Women who are sexually active or thinking about becoming sexually active. 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. For example, women who have a family history of breast, cervical or ovarian cancer can be tested for the BRCA1 or BRCA2 genes. No lump, no cancer. 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. One its drawbacks is breast tissue can overlap during compression. It's important for adult women to have annual wellness exams after the age of 21. Screening can help find breast cancer early, when it is easier to treat. Negotiated rates with providers can change, therefore, changing the estimate. Olvido su contrasea? Who Should Get It: Women age 21 - 65. The program is expected to assist Blue Cross NC in improving affordability for our members. 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. Obesity screenings. For more information, view our privacy policy. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Mammograms are for older women. Dynamic contrast material-enhanced MRI may be used to monitor response of a tumor to neoadjuvant chemotherapy used to shrink the tumor before surgery. Learn more about our other insurance plans and Medicare plans, or contact a sales . File is in portable document format (PDF). The policies were effective for diagnostic imaging services performed on or after February 15, 2007 for Blue Cross NC commercial plans. You will be required to pay the plan's physician office copayment or coinsurance. Not all employer groups participate in the diagnostic imaging management program. It often forms in the tubes that carry milk to the nipple (ducts) and in glands that make milk (lobules). When were Blue Cross NC's diagnostic imaging prior approval policies effective? Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. Find your ideal accommodation from hundreds of great deals and save with www.trivago.com Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. Enrollment in the program is automatic and available to all Blue members. Focusing on the right test at the right time for the right patient could save time and mone and increase productivity. Diagnostic mammograms more frequently than once a year, if medically necessary. About 10% of patients who receive routine mammograms get called back for another look. Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. Fargo (Headquarters) 2023 Blue Cross and Blue Shield of North Carolina. In addition, some sites may require you to agree to their terms of use and privacy policy. If physicians have questions about the Blue Cross NC diagnostic imaging management program, they should contact their local Network Management representatives. 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. It may also be used to depict residual disease after neoadjuvant chemotherapy. The remaining 40% are out-of-pocket costs. BATON ROUGE - October is Breast Cancer Awareness Month. All women need to be informed by their healthcare provider about the best screening options for them. Preventive care includes routine well exams, screenings and immunization intended to prevent or avoid illness or other health problems. Some women have a higher risk of developing cancer than other women. In contrast, 3D mammograms use CT (computed tomography) scans. Scenario 1: Brand Truvada, Viread, or Descovy may be made available if you are clinically unable to use generic Truvada. Find A Doctor Or Hospital In Your Network. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Here are some examples: Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen; Physical therapy, speech therapy and occupational therapy; Weight-reduction procedures Our goal is to review diagnostic imaging tests to determine if each test is clinically appropriate for the specific situation. 0 Side-to-side and top-to-bottom images . Still, the overall benefit of 2D and 3D breast cancer screening outweigh any potential risks linked to radiation exposure. Make sure to get all the screenings and vaccines recommended for your age and gender. Coverage is subject to the specific terms of the member's benefit plan. One option is Adobe Reader which has a built-in reader. Breast tomosynthesis is an . Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. You are leaving this website/app ("site"). NRT through QuitlineNC is available without a prescription. Cat-scan technology exposes patients to more radiation than an X-rays. Learn more about our non-discrimination policy and no-cost services available to you. Breast cancer is the most widely found cancer in U.S. women, next to skin cancer. Not all participating DME vendors carry breast pumps. You must also receive prior approval from us. Mammograms are for older women. Preventive Care. Assessing Your Risk Routine gynecological visits. Am I eligible for these benefits at 100%? For most women, mammogram technology is still considered the best way to detect breast abnormalities and cancers early. Does this prior approval impact Blue Medicare HMO and Blue Medicare PPO? Psychotherapy. to expand insurance coverage for diagnostic mammograms. In fact, we rank 32nd out of 50 states. How do 3D Mammograms Differ From Standard Ones? CT, CTA MRI, MRA, PET and echocardiography scans related to an emergency room visit, hospital stay or outpatient observation do not require prior approval. 25 - 29.9: overweight. Your doctor may order a colonoscopy more frequently than every 10 years. Currently, under the Patient Protection and Affordable Care Act Annual Checkups and certain preventive . 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.
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