HCPCS G0438 is officially defined as "Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit." HCPCS G0438 is referenced in 29 tracked payer policy changes from Anthem BCBS, Blue Cross and Blue Shield of Kansas City, and 12 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS G0438 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
Blue KC requires that drug claims follow the JW and JZ modifier rules in POL-PP-234 starting January 1, 2027, with single-dose vial waste reported on its own line with JW and zero waste reported with JZ. Effective November 1, 2026, prior authorization applies to codes L0999, E0676 and L5999 for ACA and Commercial plans, and claims for 96379 must include NDC and NDC units. Other changes were effective October 1, 2026, including the Revenue Code 0710 recovery room payment policy and new medical policies.
Effective November 1, 2026, Healthfirst bundles G2211 into the E/M service for HARP, Essential Plan and Qualified Health Plan members, and treats G0545, the listed counseling, screening and vision codes, and prolonged service codes 99415 through 99418 as inclusive to the associated E/M or preventive service for Medicaid Managed Care, Child Health Plus, HARP, Essential Plan and Qualified Health Plan members. Effective January 1, 2027, G0545 and the listed counseling, screening and vision codes are not separately reimbursable with an E/M or preventive medicine service for Medicare Advantage and CompleteCare (MAP) members, and CPT 99415 through 99418 are non-covered for those plans. Claims with G2211, G2212 or G0545 billed with an E/M service appended with modifier 25 will be denied, and G2211 is not separately reimbursable for Healthfirst Medicaid members age 21 and older.
Blue KC is implementing five major policy updates effective November 2026 through January 2027: (1) Post-Payment Clinical Claim Validation reviews with Cotiviti beginning 11/1/26 requiring medical records submission; (2) Maternity billing transition from global codes to encounter-based billing effective 1/1/27, requiring providers to bill E/M codes for individual visits starting 9/1/26; (3) Clarification that concierge services cannot be required for covered services; (4) Flu vaccine awareness guidance for high-risk members; and (5) New NDC requirement for CPT 96379 claims effective 11/1/26.
Priority Health updated multiple billing policies with key changes including new modifier requirements for surgical assistants, removal of age requirements for balloon sinus procedures, and updated Medicare Annual Wellness Visit billing to once every 12 months instead of once per calendar year.
Starting April 1, 2026, Commercial plans (Ambetter HMO/PPO and Employer Group plans) will no longer accept Medicare-specific G-codes G0402, G0438, and G0439. Providers must use standard preventive CPT codes (99381-99387 for new patients, 99391-99397 for established patients) when billing Commercial plan members for preventive visits.
Blue Cross of Idaho has updated its Risk Adjustment Accuracy (RAA) Program for 2026 performance metrics under Medicare Advantage value-based care arrangements. Participating providers must now track and meet specific targets for Annual Wellness Visit (AWV) rates and HCC Reconsideration rates, with performance measured quarterly (Q2) and year-end, using updated weighted calculations that determine performance levels 1-5.
This Maryland Medicaid MCO policy clarifies billing requirements for resident-provided E/M services under the primary care exception using the GE modifier. Teaching physicians can bill for lower- and mid-level E/M services (99211-99213, 99202-99203) and specific preventive/telehealth codes when residents work independently, but visit level selection must be based on Medical Decision Making only (not time), and teaching physicians cannot bill level 4-5 office/outpatient visits.
North Carolina Medicaid now allows scheduling of 2-year well-child visits before the child's second birthday with full reimbursement, and clarifies that well-care visits for ages 3–21 do not require 365-day spacing but are covered per calendar year. This timing change is critical for meeting immunization compliance (CIS Combo 10) and well-care quality measures.
For 2026, all Blue Cross of Idaho Medicare Advantage plans require members to choose a primary care provider, and specialty care, ancillary care and out-of-network services require a referral from that PCP, with the referral requirements detailed in MAPAP310. Referrals are good for the time span submitted by the PCP, with a maximum of 365 days, and a referral should be created for each specialty type and each condition being treated. Referrals and prior authorizations are separate processes, and the MA authorization process has not changed.
Already effective October 1, 2026, with implementation on October 5, 2026, CMS Transmittal 13803 updates Chapter 9 of the Medicare Claims Processing Manual for Rural Health Clinic and FQHC claims. CMS permanently bypasses FISS reason codes 31836 and 31837 for Category II HCPCS codes and Care Coordination Services with status indicator M or E1, and it replaces the prior virtual communication and care management sections with new ones. The update also sets out FQHC specific payment codes G0466 through G0470 and revised telehealth billing instructions, and it replaces Transmittal 13772, which covered only RHC claims, by adding FQHCs (77X TOB).
Maryland Medicaid clarifies that residents in GME programs with primary care exception can bill lower and mid-level E/M services (99202-99203, 99211-99213) using the GE modifier without teaching physician physical presence. Teaching physicians must still review care and can only use Medical Decision Making (not time) for visit level selection.
Medical Mutual requires all medical claims to be submitted electronically. Beginning September 1, 2025, it no longer accepts medical claim submissions via paper or email. Four reimbursement policies were implemented effective May 1, 2025: Emergency Department Fracture Care (RP-202506), Services and Modifiers Not Reimbursable to Health Care Professionals (RP-202507), Preventive Medicine, Screening, and Evaluation and Management Services (RP-202508), and Initial Preventive Physical Examination, Annual Wellness Visit, Preventive Medicine, and Evaluation and Management Services for Medicare Advantage (RP-202509). Regular provider notices are available only on the provider website after June 30, 2025.
Blue Cross of Idaho updated FQHC billing requirements for Medicare Advantage patients, removing MMCP/IMP billing requirements and clarifying language for Chronic Care Management (CCM), Virtual Communication Services (VCS), Psychiatric Collaborative Care Model (CoCM), and telehealth services. FQHCs must continue using specific revenue codes and HCPCS codes for qualifying services under the CMS Prospective Payment System.
Blue Cross of Idaho revised billing requirements for Rural Health Centers (RHCs) under Medicare Advantage plans, removing MMCP/IMP language from previous policy versions. RHCs must continue using specific Type of Bill 71X with designated revenue codes and CPT/HCPCS codes for qualifying visits under the CMS prospective payment system.
Blue Cross of Idaho revised its Medicare Advantage billing policy for Rural Health Clinics in September 2026 to add preventive exam language and update how care coordination, virtual communication services, psychiatric collaborative care, telehealth and vaccines are billed, following CMS coding changes. The policy gives no single effective date for the September 2026 revision, but it lists code-specific dates of January 1, 2026 and October 1, 2026, both now passed. The entry for G0511 reads 'Oct. 1, 25', which is unclear, so confirm that date with Blue Cross of Idaho.
Blue Cross of Idaho's FQHC billing policy for Medicare Advantage claims, with the September 2026 revision that added language on preventive exams. Preventive exams (CPT 99381 through 99387) are billed separately on a CMS-1500 claim, and FQHC qualifying visits need the right type of bill, revenue code and CMS payment HCPCS code, because claims missing any of these are denied and returned for correction. The policy text states no effective date of its own, so confirm the current rules on the payer's site.
Blue Cross of Idaho's billing policy for federally qualified health centers (FQHCs) on Medicare Advantage claims, last revised September 2026 to add preventive exam language. FQHC qualifying visits must carry the right type of bill, revenue code and CMS payment HCPCS code, and claims missing any of these are denied and returned for correction, so the FQHC billing team needs to confirm its claim setup against the current list.
Tufts Health Plan clarifies that annual wellness visits for Medicare members are covered on a calendar year basis (Jan 1 - Dec 31), not a rolling 365-day basis. Members may receive two covered wellness visits in fewer than 365 days if the visits occur in different calendar years. Billing teams must ensure claims are adjudicated correctly based on calendar year rather than days elapsed since the previous visit.
Blue Cross and Blue Shield of Louisiana added HCPCS codes A9596, A9601, C9094, C9095, C9096, C9097, J0739, J1306, J1551, J2356, J2779, J2998, J3299, J9331, J9332, Q4259, Q4260 and Q4261 to its claims system effective July 1, 2022. For dates of service on and after August 15, 2022, the COVID-19 treatment bebtelovimab is reimbursed when billed with Modifier UC, which identifies the medication as commercially purchased, and the same administration codes are used for commercially purchased and government-supplied medication. Updated professional allowable charges for flu vaccination codes take effect for dates of service on and after November 1, 2022, and the new charges can be viewed in the Professional Provider Allowable Charges Search tool in iLinkBlue. FEP requires prior authorization for admission to residential treatment centers, and an administrative denial results if prior authorization is not obtained or the member is not enrolled in New Directions care management.
Health Net requires Initial Health Assessments (IHA) to be completed within 120 days for all newly enrolled Medi-Cal members in specified California counties. Providers must use specific billing codes for the patient visit (99202-99215, 99381-99387, 99391-99397, 99461, G0438, G0439) and SHA assessment (96156), with documentation requirements for any exceptions.
CalViva Health (Medi-Cal) requires Initial Health Assessments (IHA) to be completed within 120 days for all newly enrolled members in Fresno, Kings, and Madera counties. Specific billing codes are provided for IHA services and Staying Healthy Assessment forms, with detailed documentation requirements and exceptions processes.
Health Net's Prop 56 Value-Based Payment (VBP) program pays add-on payments to Medi-Cal providers in Fresno, Kings and Madera counties for meeting specific measures in prenatal and postpartum care, early childhood care, chronic disease management and behavioral health integration. Payments apply to services performed on or after July 1, 2019, when submitted as a clean claim or encounter within one year from the date of service with a qualifying CPT and/or ICD-10 code. Payment amounts are higher for at-risk members, for example $70 for a prenatal care visit and $105 for an at-risk prenatal care visit, and $80 for diabetes care and $120 for at-risk diabetes care.
Health Net's Prop 56 Value-Based Payment (VBP) program pays add-on payments to Medi-Cal providers in Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus and Tulare counties for meeting specific measures in prenatal and postpartum care, early childhood care, chronic disease management and behavioral health integration. Payments apply to services performed on or after July 1, 2019, when submitted as a clean claim or encounter within one year from the date of service with a qualifying CPT and/or ICD-10 code. Payment amounts are higher for at-risk members, for example $70 for a prenatal care visit and $105 for an at-risk prenatal care visit, and $80 for diabetes care and $120 for at-risk diabetes care.
Medical Mutual updated guidelines for billing both wellness visits and sick visits on the same day for Medicare Advantage patients. When treating acute problems during an annual wellness visit, providers can bill both the wellness code (G0402, G0438, or G0439) and a problem-oriented visit code (99202-99215) but must add modifier 25 to the sick visit code only.
Blue Cross of Idaho updated its Risk Adjustment Accuracy Program (MAPAP252) to include 2026 performance metrics for Medicare Advantage value-based care participants. The policy establishes new annual targets for Annual Wellness Visit rates (40% year-end, 15% Q2) and HCC Reconsideration rates (30% year-end, 15% Q2), with providers rated across five performance levels. Billing teams at participating clinics must ensure proper capture and reporting of qualifying wellness visit codes and chronic condition diagnoses to meet these performance thresholds.
This is guidance on Medicare annual wellness visits, emphasizing that practices can bill additional E/M services with modifier 25 on the same day as the wellness visit. The policy provides coding instructions for G0402, G0438, and G0439 and workflow recommendations to optimize billing and quality metrics.
Florida Blue provides updated guidance on Annual Wellness Visit (AWV) coding and quality measures for Medicare Advantage patients. The policy emphasizes proper use of HCPCS codes G0402, G0438, and G0439 for different AWV scenarios and highlights key HEDIS quality measures to incorporate during visits.
The Annual Wellness Visit (AWV) comes in three types: the Initial Preventive Physical Examination (IPPE, also called Welcome to Medicare), the AWV, and preventive medicine or routine physical exams. Florida Blue allows one IPPE or AWV visit per calendar year per member, and the IPPE and initial AWV can be reported only once per lifetime. An optional Social Determinants of Health (SDOH) Risk Assessment is now included in the AWV, and for Medicare Advantage members the AWV and IPPE are covered under HCPCS codes G0402, G0438 and G0439.
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