My preventive screening was billed as diagnostic — what do I do?
ACA §2713 protects screening status when an incidental finding is made. Appeal.
When a screening colonoscopy or mammogram finds something abnormal, plans sometimes recode the visit as 'diagnostic' and apply cost-sharing. This violates ACA §2713 — the federal requirement that USPSTF A + B preventive services be covered at $0 cost-sharing. USPSTF guidance treats incidental findings as part of the screening.
Steps
- Call the plan and explicitly cite ACA §2713 + USPSTF guidance
- Request that the service be reprocessed as preventive at $0 cost-sharing
- If refused, file internal appeal citing ACA §2713 + USPSTF
- External review by IRO binds the plan
Frequently asked questions
My preventive screening was billed as diagnostic — what do I do?
When a screening colonoscopy or mammogram finds something abnormal, plans sometimes recode the visit as 'diagnostic' and apply cost-sharing. This violates ACA §2713 — the federal requirement that USPSTF A + B preventive services be covered at $0 cost-sharing. USPSTF guidance treats incidental findings as part of the screening.
What are the steps?
1. Call the plan and explicitly cite ACA §2713 + USPSTF guidance; 2. Request that the service be reprocessed as preventive at $0 cost-sharing; 3. If refused, file internal appeal citing ACA §2713 + USPSTF; 4. External review by IRO binds the plan
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