What are the guidelines for annual exams?

Some health care providers have asked us: How many physical exams do Blue Cross Blue Shield of Michigan or Blue Care Network members qualify for each year? The answer depends on what type of plan a member has.

• For members who have BCN coverage, there are no limits on how many times a member can schedule a physical, sometimes called a health maintenance exam.
• Members with Blue Cross Blue Shield of Michigan commercial coverage typically qualify for one physical per year under the terms of the Affordable Care Act, but some members may qualify for more, depending on their age, sex and the type of plan they have. Also, keep in mind that government guidelines for commercial coverage don’t apply to members who are part of the Federal Employee Program®, Michigan Public School Employees' Retirement System, the UAW Retiree Medical Benefits Trust or other retiree or self-funded groups that don’t follow government rules.
• Members with Medicare Advantage plans qualify for annual wellness visits. We’ll have more details on “Welcome to Medicare visits” in the January Record.

Because of these variations in coverage, it’s always best to check benefits and eligibility for your patients on web-DENIS.

Finding benefit information on web-DENIS
To find information on web-DENIS about how many physical exams are covered per calendar year for a specific member, you can follow these steps:

• From the homepage of web-DENIS, click Subscriber Info., then Eligibility/Coverage/COB. Type in the member’s contract number and click Enter.
• Select the member, and in the Detailed Benefits column, click MED (for medical benefits).

If you entered a Michigan-based contract number, you’ll be routed to the Explainer tool. Here’s what to do next:

• Click Topic.
• Under Unique Identifier, select HCPCS Code and type in the appropriate physical exam code (for example, *99395). Click Finish and then Search.
• Click the Benefit Package Report tab, then Coverage Limitations to determine requirements for that contract.

If you entered a national contract number, you’ll be routed to a NASCO benefits page. Here’s what to do next:

• Select your provider type (usually General Practice or OB-GYN for preventive care) and click GO.
• Scroll down to PHYSICAL EXAM to view any limitations.