Ambetter from NH Healthy Families: 3D Mammograms

Date: 06/08/17

Ambetter from NH Healthy Families understands the importance of easy access to care. So, we are committed to ensuring our covered services continue to be appropriate and efficient. We are happy to inform providers that 3D mammography is a covered service for members with dates of service on or after January 1, 2017. Please find coverage details below:

Coverage:

Coverage is provided for medically necessary breast cancer screening mammography to help detect and treat breast cancer early.

Coverage for preventive breast cancer screening services includes (but is not limited to):

·         Routine/preventive clinical breast exams yearly for Members over age 35.

·         Low-dose x-ray mammography as part of a complete breast exam (preventive services).

·         Any additional mammography views that are required for proper evaluation.

·         3D mammography (preventive) covered yearly for Members over age 35

·         Diagnostic mammograms (Cost Sharing Applies): when medically necessary, when abnormalities are found.

·         For screening results that suggest breast cancer, additional services (such as biopsies & ultrasounds) may be covered when deemed medically necessary.

Criteria:

Breast cancer screening mammography (including 3D) is covered as a preventive service benefit for Members over the age of 35, once per benefit year. For Members under the age of 35, mammography screenings (including 3D) are not considered preventive services and will fall under the diagnostic radiology cost sharing requirements depending on the Member’s plan type.

Member Cost Share:

Preventive services should be billed with the appropriate preventive (routine) or screening diagnosis code. If services are billed with medical (diagnostic) services code(s), they may be subject to additional cost sharing requirements depending on provider type and place of service.

Preventive Screening Codes ($0 Cost Share): 77063, 77067, G0202

Diagnostic Codes (Cost Sharing Applies): 77061, 77062, G0204, G0206 and G0279

As a reminder, services are covered for participating Ambetter providers only.

Please contact Provider Services with any questions at: 1-844-265-1278