Medicaid Update – New Preventive Visits Policy

Effective January 1, 2016, the Department of Community Health will implement a change to its existing physician office visits policy in order to allow Medicaid eligible members to have access to preventive health services. Members 21 years of age and older will now be able to access one preventive health visit each calendar year (CY) and 10 office visits (evaluation and management codes 99201 to 99215) each CY. The Department encourages primary care practitioners (PCPs) of the following types to perform the preventive health visits: physicians (internists, family physicians, or OB/GYN specialists), certified nurse practitioners, or physician assistants. FQHCs and RHCs may bill for these provider types performing preventive health visits within the FQHC or RHC. Additional office visits (above the 10 visits) will still be available based upon documentation and supporting medical necessity that must be sent to Alliant/Georgia Medical Care Foundation (GMCF) for review. This policy change supports the Department’s goal to improve the health outcomes of our enrolled Medicaid members by allowing them to establish a medical home and receive preventive health services. The establishment of a medical home will also support the Department’s efforts to reduce hospital re-admissions.

Providers may bill ONE (1) preventive health visit (993XX) for a member annually (between January and December of the CY). Providers must use one of the following ICD-10 diagnosis codes when billing the preventive health visit code: Z00.00 or Z00.01 (Encounter for adult examination). Each member is allowed 10 office visits (992XX) per CY without prior authorization. The following preventive visit codes are billable for this policy change:

99385 or 99395 (Adults 21 through 39 years of age). This code is currently open for members under the age of 21 years in the Health Check program (COS 600),

99386 or 99396 (Adults 40 through 64 years of age), and

99387 or 99397 (Adults 65 years and older).

The Georgia Medicaid Management Information System (GAMMIS) will be configured to align with these changes. We anticipate the configurations will be complete by the second quarter of CY 2016. Providers may begin billing for the preventive health visits in January 2016. Reimbursement will not be available until GAMMIS is configured according to the new policy. Please keep your claims timely for the future mass adjustment.

If you have any questions regarding this policy change, please contact HPE’s Customer Call Center at 1-800-766-4456.