×
Advance Health Equity
Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health:
×
Overview
This educational tool helps you properly provide and bill Medicare preventive services. The term “patient” refers to a Medicare beneficiary. Service information includes, as applicable:
- National Coverage Determinations (NCDs)
- HCPCS & CPT codes
- Prolonged preventive services (
) information - ICD-10-CM diagnosis codes
- Telehealth eligibility
- Coverage requirements
- Frequency requirements
- Patient cost sharing
Substantive content changes are in dark red.
Eligibility
When you request a Medicare patient’s eligibility status, we either give the dates they may get certain preventive services or give you data to help determine the next eligible date. If you’re unable to get this data, contact your eligibility service provider. Find more information in this tool’s FAQs or the Checking Medicare Eligibility fact sheet.
FAQs
How do I determine the last date a patient got a preventive service so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?
Learn how to check eligibility. You may access eligibility information through the CMS HIPAA Eligibility Transaction System (HETS) either directly or through your:
- Eligibility services vendor
- Medicare Administrative Contractor (MAC) provider call center interactive voice response (IVR) unit
- MAC provider web portal
Contact your eligibility service vendor or find your MAC’s website.
My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?
We offer a Preventive Services Checklist so they can track their preventive services.
When can CMS add new Medicare preventive services?
We may add preventive services coverage through the National Coverage Determination (NCD) process if the service is:
- Reasonable and necessary for prevention or early detection of illness or disability
- U.S. Preventive Services Task Force (USPSTF)-recommended with grade A or B
- Appropriate for people entitled to Part A benefits or enrolled under Medicare Part B
We may also add preventive services through statutory and regulatory authority.
USPSTF Published Recommendations has more preventive services information.
What’s a primary care setting?
We define a primary care setting as a place where clinicians deliver integrated, accessible health care services and are responsible for addressing most patient health care needs, developing a sustained patient partnership, and practicing in the context of family and community. Under this direction, we don’t consider emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as primary care settings.
Resources
Disclaimers
CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).