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.

The USPSTF Published Recommendations webpage 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.