Annual Physical Examinations

Overview
Annual physical examinations are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury and are not considered medically necessary to treat an illness or injury.  

Original Medicare  
Original Medicare covers a broad range of preventive services. There are two types of annual preventive office visits that are covered by Original Medicare. 

• Initial Preventive Physical Examination (also known as the “Welcome to Medicare” physical exam); this visit must occur no later than 12 months after the effective date of the beneficiary’s first Part B coverage period. This visit consists of a one-time review of the beneficiary’s health status and risk factors and provides education and counseling about preventive services and the development of a personalized prevention plan for the beneficiary. 
• The Annual Wellness Visit (AWV) is covered for a beneficiary who has had Part B coverage for longer than 12 months and who has not received either a Welcome to Medicare or AWV within the past 12 months. The purpose of the AWV is to develop and/or update an existing personalized prevention plan based on the beneficiary’s current health and risk factors.  

Original Medicare does not cover Annual Physical Examinations or Preventive Visits (other than those described above).  

BCBSNE Medicare Advantage (MA) Enhanced Benefit  
The Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage plans provide at least the same level of benefit coverage as Original Medicare (Part A and Part B) and may provide enhanced benefits beyond the scope of Original Medicare within a single health care plan. This flexibility allows BCBSNE to offer enriched plans by using Original Medicare as the base program and adding desired benefit options.  

Coverage for an Annual Physical Examination is provided to members under the MA plans. Since Original Medicare does not cover Annual Physical Examinations, the scope of the benefit, reimbursement methodology, maximum allowed payment amounts and member cost sharing are determined by BCBSNE for individual coverage.  

The annual physical exam includes a detailed history and physical that focuses on the member’s medical history, family history, and the performance of a detailed head to toe assessment with a hands on examination of all body systems. For example, the practitioner must use visual inspection, palpitation, auscultation and manual examination of the enrollee to assess overall general health and detect abnormalities or signs that could indicate a disease process that should be addressed. There is no member cost-share for the visit itself for members with individual coverage. However, additional cost-share may apply for any service that does not fall within the scope of a preventive screening or covered immunization as defined under Original Medicare. 

Conditions for Payment  

Reimbursement 
BCBSNE MA plans’ maximum payment amount to providers is available on our provider website, (NaviNet.net ) in the MA enhanced benefits fee schedule or in the Explanation of Coverage at Medicare.NebraskaBlue.com/MedicareAdvantage/PlanDetails.  

The provider will be paid the lesser of the allowed amount or the provider’s charge, minus the member’s cost-share. This represents payment in full and providers are not allowed to balance bill the member for the difference between the allowed amount and the charge.  

Member Cost-sharing 

• BCBSNE Medicare Advantage providers should collect the applicable cost-sharing from the member at the time of the service when possible. Cost-sharing refers to a flat-dollar copayment, a percentage coinsurance or a deductible. Providers can only collect the appropriate BCBSNE MA cost-sharing amounts from the member.  
• If the member elects to receive a non-covered service, he or she is responsible for the entire charge associated with the non-covered service.  

To verify benefits and cost share, providers may call 888-505-2022.  

Billing Instructions for Providers 

1. Bill services on the CMS 1500 (02/12) claim form.
2. Use the BCBSNE MA unique billing requirements.  
3. Report CPT/HCPCS codes and diagnosis codes to the highest level of specificity.  
4. Include your National Provider Identifier number on all claims.  
5. Send your claims to your local BCBS plan. 

 
Revision History:  
Policy Number: NEHMO 1002  
Policy Revised : 01/2020  
Policy Effective: 01/01/2017 Y0139_Annual