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Provider Manual

Billing

Last Updated on August 28, 2018

Preventive Care

HealthCheck exams must be billed using any of the following CPT codes.  Please refer questions to the ForwardHealth portal.

New Patient

99381 Initial preventive medicine visit, age younger than 1 year

99382 Initial preventive medicine visit, age 1 through 4 years

99383 Initial preventive medicine visit, age 5 through 11 years

99384 Initial preventive medicine visit, age 12 through 17 years

99385 Initial preventive medicine visit, age 18 to 21 years

Established Patient

99391 Periodic preventive medicine, age younger than 1 year

99392 Periodic preventive medicine, age 1 through 4 years

99393 Periodic preventive medicine, age 5 through 11 years

99394 Periodic preventive medicine, age 12 through 17 years

99395 Periodic preventive medicine, age 18 through 20 years

If a member needs a referral or follow-up visit for diagnostic or corrective treatment, the “UA” modifier must be attached to the above codes in the first modifier field.

If no referral or follow-up is needed, providers should indicate only the procedure code.

Newborn Exams

Please note the newborn exam in the hospital counts as the first HealthCheck if billed with either of the following CPT codes:

99460 History and examination of the normal newborn infant. (This code should also be used for birthing room deliveries.)

99463 History and examination of the normal newborn infant. (This code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date).

Billing for a HealthCheck Exam When Primary Insurance Exists Often times a Security Health Plan BadgerCare Plus member has a primary insurance. The primary insurance must be billed for the preventive exam (HealthCheck exam) first. If primary insurance denies payment or partially pays, follow the normal billing process to Security Health Plan by attaching an Explanation of Benefits (EOB) to the claim submission.

If the member’s primary insurance pays in full for the preventive exam (HealthCheck exam), the provider must also notify Security Health Plan of the exam in order to receive compliance credit for the exam. Submit a claim and EOB as above.

Billing Primary Insurance

If a provider is having trouble getting a response from the primary insurance, or there is something that is causing a delay in submitting the HealthCheck exam because of the primary insurance, please send the claim along with a detailed explanation of what has been attempted to resolve the situation. Security Health Plan will assess these circumstances on a case-by-case basis and if appropriate, may process without the primary EOB. Please send these specific cases to the attention of the COB Department Manager.

If a comprehensive HealthCheck exam does not result in a referral for further evaluation or treatment, providers should only indicate the procedure code. Modifier “UA” is the national modifier that is state defined by Wisconsin Medicaid for providers to use to indicate that a comprehensive HealthCheck exam resulted in a referral for further evaluation or treatment.