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Preventive services are services provided with the intent of identifying risk factors and screening for specific conditions. The goal is to prevent future health conditions. Preventive services do not include the evaluation or treatment of existing concerns. WEA Trust follows federal guidelines for defined preventive services, outlined by the U.S. Preventive Services Task Force.
Each service you receive from your medical provider is submitted to us with a diagnosis and procedure code. The combination of these codes represents the service provided. If the service is identified as a preventive service and you use a network provider, you will not pay anything out-of-pocket.
If the diagnosis code represents the evaluation or treatment of a medical condition, then that service would be subject to applicable copay, deductible, or coinsurance.
Many vaccines are considered preventive, such as: Hepatitis A, Measles, Mumps, Rubella, Hepatitis B, Meningococcal, Herpes Zoster, Pneumococcal, Human Papillomavirus, Tetanus, Diphtheria, Pertussis, Influenza and Varicella.
When services are provided to evaluate and manage an existing illness or condition, they are not considered preventive. For example, if you ask your provider about your knee pain and she evaluates and prescribes medication, you might have to pay for this additional, non-preventive service. Even if you are visiting your provider for a preventive care visit, ask to be sure all services provided are considered preventive.
If I go in for routine services to monitor an existing illness or condition?
No, routine services to monitor diabetes, hyperlipidemia, hyper cholesterol, etc. are not considered a preventive service. They are being done to evaluate and manage an existing illness or condition.
If I get a preventive lab/MRI from a Network provider, but it gets sent to a non-Network provider for the reading?
If the lab/MRI is billed as a preventive service and is rendered by a Network provider, the reading with the non-Network provider will be reimbursed at your Network benefits level. We will not apply any deductible or coinsurance; however, services are subject to the maximum allowable fee (MAF). Any charge above MAF will be your responsibility.
If I have a mammogram and it is determined that an MRI is needed for a more accurate screening due to fibrous or dense breast tissue?
Yes, an MRI of the breast would be considered a preventive service. Therefore, it is not subject to the applicable deductible and coinsurance, as long as you used a Network provider.
If my physician orders a screening colonoscopy and polyps are found and removed?
Yes, as long as you used a Network provider. Accurate coding by the clinic or facility is also necessary to identify the service as preventive.
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