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Prior Authorization – Preventive Care Services

HCP providers are strongly encouraged to engage with every patient annually to ensure their health and wellness initiatives are kept current.

Preventive Screening Services are made available to all patients without Prior Authorization limitations when performed by a PCP or by a Preferred Specialist Network physician. Services are most cost effectively provided through outpatient-based resources such as provider offices and free standing imaging and surgical centers, limiting the use of hospital-based services to only those whose health would be adversely impacted by using freestanding sites of service.

The following Preventive Screening services, when delivered by PCPs or PSN Specialists, require no Prior Authorization when performed in the office or in a freestanding (non-hospital affiliated) center*.

*For Mammography Screening, no Prior Authorization is required at any health plan in-network site of service, although, non-hospital radiology centers are preferred. 

Preventive ServiceProcedure CodesICD-10 Diagnosis CodesCoverage Parameters
Preventive Screening99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 92002, 92004, 92012, 92014, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, S0620, S0621, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215,  99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99483, G0402, G0438, G0439, G0463, T1015AllFrequency: One procedure code/member/year
Ages: All
Gender: M/F
Examination and Counseling Services96160, 96161AllFrequency: One procedure code/member/year
Ages: All
Gender: M/F
Examination and Counseling Services99401, 99402, 99403, 99404AllFrequency: One procedure code/member/year
Ages: All
Gender: M/F
Examination and Counseling ServicesG0513, G0514AllFrequency: One procedure code/member/year
Ages: All
Gender: M/F
Abdominal Aortic Aneurysm (AAA) Screening76706F17.200, F17.201, F17.203, F17.208, F17.209, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A, Z13.6, Z87.891Frequency: 1x/lifetime
Ages: 65-75 years
Gender: M
Alcohol Screening99408, 99409, G0396, G0397, G0442, G0443Z13.89Frequency: 1x/year Ages: All
Gender: M/F
Autism, Psychosocial/Behavioral and Developmental Screening96110, 96127Z00.121, Z00.129, Z13.89, Z13.41, Z13.42Frequency: 1x/year
Ages: 0 – 21 years
Gender: M/F
Anemia (General) via Quest Labs85025Z00.00, Z00.01, Z00.121, Z00.129, Z01.411, Z01.419, Z00.5, Z00.70, Z00.71, Z00.8Frequency: 1 x/year
Ages: All
Gender: M/F
Breast Supplemental Screening and Diagnostic Imaging76641, 76642, 77058, 77059NoneFrequency: 1 x/year
Ages: All
Gender: F
Breast Tomosynthesis77061, 77062, 77063, G0279NoneFrequency: 1 x/year
Ages: 40 years and over
Gender: F
Chlamydia Screening via Quest Labs86631, 86632, 87110, 87140, 87270, 87320, 87490, 87491, 87492, 87800, 87801, 87810AllFrequency: 1x/year Ages: All
Gender: F
Colon Cancer Screening (Anesthesia and Ancillary Services)00812AllFrequency: Once every 5 years
Ages: 50-75 years
Gender: M/F
In Network Anesthesiology Services Required
Colon Cancer Screening44388, 44389, 44391, 44392, 44394, 45300, 45303, 45305, 45308, 45309, 45315, 45317, 45320, 45330, 45331, 45333, 45338, 45346, 45378, 45380, 45382, 45384, 45385, 45388, 74263, 45379, 45381, 45386, 45389, 45390, 45391, 45392, 45393, 45398, 44390, 44393, 44397, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 74261, 74262, 45332, 45334, 45335, 45337, 45339, 45340, 45341, 45342, 45347, 45349, 45350Z00.00, Z00.01, Z12.12, Z12.10, Z12.11, Z80.0, Z83.71, Z83.79Frequency: Once every 10 years
Ages: 50 – 75 years
Gender: M/F
Colorectal Cancer ScreeningG0104, G0105, G0106, G0120, G0121, G0122K50.00, K50.011, K50.014, K50.018,K50.019, K50.10, K50.111, K50.114, K50.118, K50.119, K50.80, K50.811, K50.814, K50.818, K50.819, K50.90, K50.911, K50.914, K50.918, K50.919, K51.20, K51.211, K51.214, K51.218, K51.219, K51.30, K51.311, K51.314, K51.318, K51.319, K51.80, K51.811, K51.814, K51.818, K51.819, K51.90, K51.911, K51.914, K51.918, K51.919, K52.1, K52.89, K52.9, Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79Frequency: Once every 5 years
Ages: 50 – 75 years
Gender: M/F
Colon Cancer Screening (Pathology) via Ameripath or Quest Labs88305Z00.00, Z00.01, Z12.12, Z12.10, Z12.11, Z80.0, Z83.71, Z83.79Frequency: once every 5 years
Ages: 50 – 75 years
Gender: M/F
Colon and Colorectal Cancer Screening (Stool For Occult Blood – Lab Test)82270, 82274, G0328Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79Frequency: 1X year
Ages: 50 – 75 years
Gender: M/F
Colorectal Cancer Screening (Cologuard ® Lab Test)81528, G0464Z12.10, Z12.11, Z12.12, Z80.0Frequency: once every 3 years
Ages: 50 – 85 years
Gender: M/F of average cancer risk
Developmental Screening96110, G0451Z13.41, Z13.42, Z13.89Frequency: 1x/year
Ages: up to age 18
Gender: M/F
Diabetes Screening via Quest Labs82947, 82948, 82950, 82951, 82952, 83036Z13.89, Z13.41Frequency: 1x/year
Ages: All
Gender: M/F
Diabetes Screening: Gestational via Quest Labs82947, 82948, 82950, 82951, 82952, 83036, 83036, 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156Z13.42Frequency: 2x/year
Ages: All
Gender: F
​Diabetic Retinal Screening67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, S0620, S0621, S3000, 2022F, 2024FE10.1, E10.6, E11.1, E11.2, E11.6Frequency: 1x/year
Ages: All
Gender: M/F
Spirometry94010, 94014, 94015, 94016, 94060, 94070, 94375J42, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1,  J44.9Frequency: 1x/year
Ages: All
Gender: M/F
For diagnosis of COPD
Gynecological Exam99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397Z01.411, Z01.419Frequency: 1x/year when provided by OB/Gyn or PCP Ages: All
Gender: F
Hearing Screening92551, 92552, 92553, 92568, 92585, 92586Z00.00, Z00.01, Z01.10, Z01.12, Z00.121, Z00.129Frequency: 1x/year
Ages: 0 – 21 years
Gender: M/F
Hepatitis B Screening via Quest Labs86704, 86706, 87340, 87341, G0499AllFrequency: 1x/year
Ages: All
Gender: M/F
Hepatitis C Screening via Quest Labs86803, G0472Z20.5, Z20.6, Z20.828, Z72.89Frequency: 1x/year
Ages: 50+
Gender: M/F
HIV Screening via Quest LabsG0432, G0433, G0435, G0445, G0475Z00.00, Z00.01, Z00.121, Z00.129, Z11.3, Z11.4, Z11.59, Z20.6, Z22.6, Z22.8, Z22.9, Z71.7Frequency: Unlimited
Ages: All
Gender: M/F
Human Papilloma Virus (HPV) Screening via Quest Labs87623, 87624, 87625Z00.00, Z00.01, Z00.121, Z00.129, Z00.8, Z01.411, Z01.419, Z11.51, Z12.4Frequency: 1x/year
Ages: All
Gender: F
Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests via Quest Labs (paid when billed by a laboratory only)G0476Z00.00, Z00.01, Z01.411, Z01.419, Z11.51, Z12.4Frequency: 5x/year
Ages: 30 – 65
Gender: F
Lead Screening via Quest Labs83655Z00.121, Z13.88, Z77.011Frequency: 1x/year
Ages: 0-6 years
Gender: M/F
Lipid Screening via Quest Labs80061, 82465, 83718, 83719, 83721, 84478Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.220, Z13.6, Z13.228, Z13.818Frequency: 1x/year
Ages: All
Gender: M/F
Lung Cancer Screening at a free standing Radiology CenterG0296, G0297F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891, Z12.2Frequency: 1x/year
Ages: 55 +
Gender: M/F
Mammography Screening all Sites of Service77067, 77065, 77066, G0202, G0204, G0206Z12.31, Z12.39Frequency: 1x/year
Ages: 40+ years
Gender: F
Newborn Screening: Hearing92558AllFrequency: 1x/year
Ages: 0-3 months
Gender: M/F
Newborn Screening: Hypothyroidism84437, 84443Z13.29Frequency: 1x/year
Ages: 0-3 months
Gender: M/F
Newborn Screening: PKU84030, S3620Z13.0, Z13.21, Z13.228, Z13.29Frequency: 1x/year
Ages: 0-3 months
Gender: M/F
Newborn Screening: Sickle Cell Disease83020, 83021, 83051, S3850Z13.0, Z13.21, Z13.228, Z13.29Frequency: 1x/year
Ages: 0-3 months
Gender: M/F
Osteoporosis Screening via office or free standing imaging center76977, 77078, 77080, 77081, 77085, G0130, 76977, 77078, 77080, 77081, 77085, G0130AllFrequency: Every 23 months
Ages: 60+ years
Gender: F
Pap Smear via Quest Labs87081, 87205, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, Q0091Z00.00, Z00.01, Z01.411, Z01.419, Z11.3, Z12.4, Z12.72, Z12.0, Z12.79, Z12.89, Z77.110, Z77.111, Z77.112, Z77.118, Z77.122, Z77.123, Z77.128, Z77.21, Z77.22, Z77.9, Z91.82, Z91.89, Z92.89Frequency: 1x/year
Ages: All
Gender: F
Pregnancy, Bacteriuria Screening via Quest Labs81007, 87086, 87088AllFrequency: Unlimited
Ages: All
Gender: F
Pregnancy, Blood Count via Quest Labs85025, 85027AllFrequency: Unlimited
Ages: All
Gender: F
Prostate Cancer Screening via Quest Labs84152, 84153, 84154, G0102, G0103Z12.5Frequency: 1x/year
Ages: 40+
Gender: M
Obstetric panel (includes HIV testing) via Quest Labs80081AllFrequency: 1x/year
Ages: All
Gender: F
Pregnancy, Hepatitis B Screening via Quest Labs87340, 87341AllFrequency: 1x/year
Ages: All
Gender: F
Pregnancy, Rh (D) Typing via Quest Labs86901AllFrequency: Unlimited
Ages: All
Gender: F
Pregnancy Screening Panel via Quest Labs
– Includes Hepb, Blood Count, Rh (D), Syphilis
80055AllFrequency: 1x/year
Ages: All
Gender: F
Syphilis Screening via Quest Labs86592, 86593, 86780, 87164, 87166, 87285AllFrequency: 1x/year
Ages: All
Gender: M/F
TB Testing86480, 86580R76.11, R76.12, Z00.121, Z00.129, Z11.1, Z20.1Frequency: 1x/year
Ages: All
Gender: M/F
Vision Screening in Children
99172, 99173Z00.121, Z00.129, Z01.00, Z01.01Frequency: 1x/year
Ages: 0-21 years
Gender: M/F
99174, 99177Z00.121, Z00.129, Z01.00, Z01.01Frequency: 1x/year
Ages: 1-4 years
Gender: M/F
Immunization administration90460, 90461, 90471, 90472, 90473, 90474, G0008, G0009, G0010AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria, tetanus (DT)90702AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria, tetanus, acellular pertussis (DTaP)90700AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria, tetanus, acellular pertussis (Tdap), age 7 or older90715AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria, tetanus, acellular pertussis, Hepatitis B, polio (DtaP-HepB-IPV)90723AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age90696AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria, tetanus, acellular pertussis, HIB, polio (DTaP- HIB-IPV)90698AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Diptheria preservative free, tetanus (Td), age 7 or older90714, 90715AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Hepatitis A90632, 90633, 90634AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Hepatitis A/Hepatitis B Combo90636AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Hepatitis B90739, 90740, 90743, 90744, 90746, 90747, G0010AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Hepatitis B/HIB Combo90748AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Herpes Zoster Vaccine90736, 90750AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
HIB (Hemophilus influenza b)90647, 90648AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
HPV (Human Papillomavirus) Vaccine90649, 90650, 90651AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Influenza (flu) Vaccine90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90672, 90674, 90673, 90682, 90685, 90686, 90687, 90688, 90689, 90756, G0008, Q2034, Q2035, Q2036, Q2037, Q2038AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Measles-Mumps-Rubella (MMR) Virus Immunization90707AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Measles-Mumps-Rubella- Varcella (MMRV)90710AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Meningitis Vaccine90733, 90734AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Meningococcal Vaccine90620, 90621AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Meningitis-HIB Vaccine90644AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Pneumococcal Vaccine, 13 valent90670, G0009AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Pneumococcal Vaccine– Over age 2 and adult90732, G0009AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Poliomyelitis, inactivated (IPV) Immunization90713AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Rotavirus Vaccine90680, 90681AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Rubella Immunization Status86762AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Varicella90716AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.
Zoster90750AllProvider must adhere to FDA/CDC
age/frequency/gender guideline.