AmeriHealth members – and their providers – often have questions when scheduling appointments for receiving annual preventive service visits, especially well-care visits. AmeriHealth members have coverage for one well-care visit every calendar year. They do not need to wait 365 days between visits. A member can schedule an annual well-care visit/physical exam at any time during each calendar year.
An AmeriHealth member who visits a primary care provider (PCP) or personal physician for an annual physical on October 31, 2019, does not have to wait until October 31, 2020, for another physical. The member may schedule their next physical any time on or after January 1, 2020.
Services that occur less frequently (other than once per year) adhere to a rolling calendar year. For example, when normal, a colonoscopy would be covered once every ten years.
Coverage for annual well-care visits is based on a calendar year regardless of the member’s benefit period. Whether an AmeriHealth member has a calendar year benefit period or a group contract year benefit period, the benefit time period for preventive services remains the same. Self-funded group benefit periods may vary, but this does not affect preventive care annual visits.
Note: Pediatric members may have coverage for more frequent visits depending on their age.
Annual well-care visits include services such as:
- physical/wellness exam
- depression screening
- risk assessment for sexually transmitted diseases
Coverage for preventive services
All benefit limits are subject to age requirements as outlined in the AmeriHealth Medical Policy #00.06.02aa: Preventive Care Services. To access this policy, visit our Medical Policy Portal.
Verifying member benefits
It is important for providers to verify benefit coverage prior to scheduling and/or performing preventive services. Providers can check the member’s coverage through the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal (NaviNet Open) by selecting Additional Benefit Provisions and then choosing Routine/Preventive Care.
For instructions on how to use this transaction, refer to the Eligibility and Benefits Inquiry Guide, which can be found under User guides and webinars in the NaviNet Open section.
If you have additional questions about member benefits and annual preventive service visits, please call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.
NaviNet® is a registered trademark of NantHealth.