PEHP generally pays in-network preventive visits at 100%. However, you’ll be billed if you get additional treatment or services at your preventive visit. An “additional service” could be something as minor as a discussion with your doctor about a past or current condition.
Example: You schedule a preventive service. While at your appointment, your doctor asks if you have any symptoms or complaints. You tell the doctor about recent knee pain, which she exams and diagnoses. The doctor's office bills PEHP with a charge for the preventive exam and a separate charge for the exam of the knee. PEHP will pay 100% of the charge for the preventive exam (if you used an in-network provider), but you may be responsible for a portion of the bill for the knee exam.
Certain screenings, such as a blood test, colonoscopy, or mammogram, may identify health conditions that require further testing or treatment. If a condition is identified through a preventive screening, any subsequent testing, diagnosis, analysis, or treatment at the same appointment may be billed separately from the preventive visit.
Example: You schedule a cholesterol screening (an eligible preventive service for adults over a certain age). Your doctor orders blood tests, which reveal your cholestrol is high. During the visit, your doctor discusses how to manage the condition and prescribes medication. The doctor's office bills PEHP with a charge for the cholesterol screening and a separate charge for the treatment of high cholestorol. PEHP will pay 100% of the charge for the eligible preventive exam (if you used an in-network provider), but you may be responsible for a portion of the bill for the treatment of high cholestorol.
Ask your doctor how your visit will be billed; PEHP pays based on how it’s billed.