Preventive vs Diagnostic Service FAQ
To understand whether a service is preventive or diagnostic, it’s important to discuss your ongoing care with your physician. You can also call the Member Service number on the back of your member ID card if you have questions about which services are fully covered. Diagnostic services may require a copay, coinsurance, or deductible — as indicated by your health plan.
Preventive screenings are routine tests that can help you stay well by finding or detecting problems early, when they’re easier to treat. They’re administered when you don’t have symptoms or a current diagnosis of disease. For example, Pap smear screenings can be done annually or every three years to detect cervical cancer.
Preventive care also includes services like:
- Annual wellness visits.
- Immunizations like flu shots.
- Certain lab tests like cholesterol checks.
Diagnostic services and tests are prescribed by a doctor when you’ve been diagnosed with a disease or have symptoms that need to be evaluated. These services may also include test results that may have been abnormal or not in a normal range. For example, if you’re experiencing cervical pain or bleeding, your doctor may prescribe a more comprehensive diagnostic Pap smear test. This is different than a preventive Pap smear screening.
Diagnostic care may also be given during your preventive care visit. For example, during an annual wellness visit, if your doctor is treating a chronic condition, they may want to investigate further by ordering additional tests. These may require a copay, coinsurance, or deductible. Other types of diagnostic services can include:
- X-rays.
- Ultrasound examinations.
- Laboratory blood tests for diagnosed high cholesterol and diabetes.
The preventive schedules Highmark uses are based on the federal mandates under the Patient Protection and Affordable Care Act (PPACA) from the United States Preventive Services Task Force (USPSTF), and the immunization schedule from the American Academy of Pediatrics’ Bright Futures initiative and the Centers for Disease Control and Prevention (CDC). State mandates are also followed.
Both types of screenings may be covered at no cost to our members. In most cases, there is no cost for preventive screenings. However, cost-sharing practices like copays, deductibles, and coinsurance may apply to diagnostic care received at an appointment, even if it’s a preventive office visit. It’s best to check with your doctor, contact us through the member portal, or call the Member Service number on the back of your member ID card.
- Log in to your member portal.
- On the homepage, click the Wellness tab at the top of the page.
- Under the Plan Your Preventive Care section, locate the preventive schedule.
