Provider Education

• The Annual Wellness Visit (AWV) is a preventive wellness visit and is not a “routine physical checkup” or “annual physical.” Medicare provides coverage for the Initial Preventive Physical Exam (IPPE) and AWV as a Medicare Part B benefit. BCBSAZ Health Choice Pathway provides an additional non-Medicare covered benefit associated with the AWV to allow multiple times per year if necessary. The member will pay nothing for the AWV (there is no coinsurance or copayment and no Medicare Part B deductible for this benefit).
• The AWV must be furnished by a health professional, meaning a physician (a doctor of medicine or osteopathy), a qualified non-physician practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist), or by a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician.
• Medical record documentation must show that the health professionals provided, or provided and referred, all required components of the AWV.
  • G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
  • G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit
  • G0468* – Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV
• BCBSAZ Health Choice Pathway will allow billing for G0438 and G0439 any time during the year.

Certain benefits under the BCBSAZ Health Choice Pathway plan require a referral or prior authorization. PCPs are required to coordinate the member’s care by sending the member to a contracted BCBSAZ Health Choice Pathway specialist. If a member receives healthcare services from any physician, hospital or other healthcare provider without getting a referral or authorization in advance, the member may have to pay for these services. Please click on the “Find a Doctor” link for a complete listing of BCBSAZ Health Choice Pathway providers.

The BCBSAZ Health Choice Pathway Summary of Benefits and Evidence of Coverage list the benefits which are covered by our plan. Chapter four in the Evidence of Coverage lists covered services that need prior authorization.

There are many services a member may obtain on their own, without prior approval from a provider or BCBSAZ Health Choice Pathway.

The following services are covered as Preventive Care and do not require prior authorization.

• Colorectal Screenings
• Mammography screenings
• Pap Smears, Pelvic Exams, and Clinical Breast Exam
• Prostate Cancer Screening exams
• Cardiovascular Disease Testing
• Physical exams
• Outpatient substance abuse services
• Emergency services
• Urgently needed care
• Physician services, including doctor office visits
• Flu shots and pneumonia vaccinations
• Renal dialysis services that are obtained when a member is temporarily outside the plan’s service area and for the first Renal Dialysis visit so the Health Choice Case Management department is aware of the member’s dialysis needs and can coordinate follow-up care (along with the provider). Ongoing dialysis treatment does not require additional authorization(s).

In addition to any exclusions or limitations described in the BCBSAZ Health Choice Pathway Evidence of Coverage and Summary of Benefits, the following items in the list below are NOT covered except as indicated by BCBSAZ Health Choice Pathway.

They include but are not limited to:

• Services that are not covered under Original Medicare, unless such services are specifically listed as covered in Section 4.
• Services that you get from non-plan providers, except for care for a medical emergency and urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan’s service area, and care from non-plan providers that is arranged or approved by a plan provider. See other parts of this booklet (especially Sections 2 and 3) for information about using plan providers and the exceptions that apply.
• Services that you get without a referral from your PCP, when a referral from your PCP is required for getting that service.
• Services that you get without prior authorization, when prior authorization is required for getting that service. (Section 4 gives a definition of prior authorization and tells which services require prior authorization.)
• Services that is not reasonable and necessary according to the standards of original Medicare unless these services are otherwise listed by BCBSAZ Health Choice Pathway as a covered service. As noted in Section 4, we provide all covered services according to Medicare guidelines.
• Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency. (See Section 3 for more information about getting care for a medical emergency).
• Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or unless services covered under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Choice and Original Medicare that are not generally accepted by the medical community. See Section 7 for information about participation in clinical trials while you are a member of BCBSAZ Health Choice Pathway.
• Surgical treatment of morbid obesity unless medically necessary and covered under Original Medicare.
• Private room in a hospital, unless medically necessary.
• Private duty nurses.
• Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
• Nursing care on a full-time basis in your home.
• Custodial care is not covered by BCBSAZ Health Choice Pathway unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
• Homemaker services.
• Charges imposed by immediate relatives or members of your household.
• Meals delivered to your home.
• Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary
• Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery is covered for all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast.
• Routine dental care (such as cleanings, fillings, or dentures) or other dental services. Certain dental services that you get when you are in the hospital will be covered.
• Chiropractic care is generally not covered under the plan, (with the exception of manual manipulation of the spine, as outlined in Section 4) and is limited according to Medicare guidelines.
• Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
• Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
• Supportive devices for the feet. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
• Hearing aids and routine hearing examinations.
• Routine eye examinations and eyeglasses (except after cataract surgery), radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
• Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
• Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices. (Medically necessary services for infertility are covered according to Original Medicare guidelines.)
• Acupuncture.
• Naturopath services.
• Services provided to veterans in Veteran’s Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the cost sharing required under BCBSAZ Health Choice Pathway, we will reimburse veterans for the difference. Members are still responsible for the BCBSAZ Health Choice Pathway cost sharing amount.

Please see the BCBSAZ Health Choice Pathway Prior Authorization list for more information on what services are covered and not covered by the BCBSAZ Health Choice Pathway plan.

This is not all-inclusive therefore Providers must verify both eligibility and covered benefits prior to rendering services by calling Member Services at 1-800-656-8991 (TTY 711), 8 a.m. – 8 p.m., 7 days a week.

Current Year Supplemental Benefits