Back to Insights and Updates for ProvidersSeptember 2023

Reminders and update: billing for PrEP and HIV services

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial

As you’re likely aware, the prescribing of HIV PrEP medication, as well as ongoing follow-up and monitoring and other related services, are considered preventive services and are required under the Patient Protection and Affordable Care Act to be covered with no cost sharing responsibility for the member when rendered by an in-network provider.

Related services include:

  • HIV testing
  • Hepatitis B and C testing
  • Creatinine testing and calculated estimated creatine clearance (eCrCl) or glomerular filtration rate (eGFR)
  • Pregnancy testing
  • Sexually transmitted infection (STI) screening and counseling
  • Adherence counseling
  • Office visits

When submitting claims for these services, it’s important to bill in accordance with our Harvard Pilgrim Patient Protection and Affordable Care Act (Federal Health Care Reform) policy and Tufts Health Plan Preventive Services Payment Policy to ensure that no member cost sharing is inappropriately applied.

When billing for PrEP and other HIV services for Tufts Health Plan members, providers should bill the appropriate CPT procedure code with the correct ICD-10 diagnosis code — or, for procedure codes not listed on the policy, if the claim is for an evidence-based service with a United States Preventive Services Task Force (USPSTF) A or B rating, the service may be identified by adding modifier 33 to the procedure code.

Nov. 1, 2023 billing update for Harvard Pilgrim

Currently, Harvard Pilgrim requires providers to append CPT modifier 33 (preventive service) when billing a procedure code for HIV PrEP, screening, or related services, and no specific ICD-10 diagnosis code is required.

However, effective for dates of service beginning Nov. 1, 2023 for Harvard Pilgrim Health Care commercial plans, modifier 33 will no longer be required, but these services must be billed with the appropriate ICD-10 diagnosis code in addition to the procedure code in order to be reimbursed.

For more information, please refer to the updated Harvard Pilgrim Patient Protection and Affordable Care Act (Federal Health Care Reform) policy and the Tufts Health Plan Preventive Services Payment Policy.

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