Covered Services & Billing Tips

Covered Services & Billing Tips

Our goal is to make billing and reimbursement as efficient as possible for both You First members and providers. Here are some things to remember:

  • You First members should present their member card when they check-in for their visit.
  • Office staff should check their membership via Medicaid’s Eligibility Verification System (EVS). For screening and diagnostic aid category "LF".  You First coverage will not appear in MMIS for members on Medicaid or Medicare.
  • Bill You First for covered services. Members eligible for coverage of clinical services should not receive a bill for any covered You First services. Members with Medicare Part B are not eligible for You First coverage of clinical services.
  • All Medicaid providers can bill for You First services. Others can enroll on the Vermont Medicaid Portal.
  • New members can submit eligible bills up to 90 days prior to their enrollment start date. A member's card will show their enrollment date plus a 90 day retroactive coverage period.
  • Contact us if you or your billing staff have any questions or concerns.

Covered Services

The You First program covers services in these clinical categories:

  • Breast cancer screening and diagnostic tests
  • Cervical cancer screening and diagnostic tests
  • Cardiovascular disease screenings for members 30-64

2022 Fee Schedule

 

Breast Cancer Services | Members 40+ 

  • Clinical breast exam
  • Screening Mammogram
  • Diagnostic Mammogram
  • Ultrasound
  • Consultation
  • MRIs
  • Second opinion
  • Breast biopsy

Breast cancer screening can begin sooner if recommended by provider

Cervical Cancer Services | Members 21+

  • Cervical cytology (Pap test)
  • HPV testing
  • HPV and cervical cytology cotesting
  • Colposcopy
  • Diagnostic tests

Heart Health Services | Members 30-64

A cardiovascular disease screening visit that includes:

  • Two blood pressure results
  • Height and weight screening
  • Fasting blood glucose or Hgb A1c testing (either in the office or at a lab)
  • Cholesterol test (either in the office or at a lab)

Additional Benefits

In addition to these services, all members get:

  • Personalized help understanding their screening needs, results and next steps
  • Help scheduling and arranging transportation to You First health care appointments.

Members aged 30-64 are eligible for an array of FREE lifestyle and wellness benefits, including:

  • Support from a local health coach via phone or email
  • Weight management memberships (WW - formerly Weight Watchers, etc.)
  • At-home blood pressure monitor
  • Local gym memberships and at-home fitness equipment
  • Local farmers market coupons and CSAs
  • State Park Passes

Have a patient who may be eligible for You First? Encourage them to Contact Us and we'll help them apply.

Services Not Covered by You First

  • Genetic testing and counseling
  • Pelvic and transvaginal ultrasound
  • Endometrial biopsy (unless patient has Atypical Glandular Cells of Undetermined Significance [AGUS] Pap test results).
  • Cervical conization (can be covered by the Vermont Breast and Cervical Medicaid Treatment Program if eligible)
  • Gonorrhea, chlamydia, and other STI tests
  • Electrocardiogram
  • Thyroid stimulating hormones test (TSH)
  • Bone density test

More Billing Guidance

The status and payment information of all claims submitted for processing to Vermont Medicaid for You First members can be found in the remittance advice (RA) provided by Vermont Medicaid and accessed either electronically through the Vermont Medicaid Portal or received weekly by mail. If you have questions or need assistance in understanding the reason for a claim denial, please contact us.

The You First fee schedule is in accordance with the CDC guidelines and all fees are based on the average Medicare Part B rate. As a You First provider, you agree to write-off any remaining balances of You First covered procedures and not bill the members.

  • Bill primary insurance first. You First is the payor of last resort.
  • Submit billing through the Vermont Medicaid billing system with Gainwell Technologies.
  • If you have any billing questions, please contact the You First program at 800-508-2222 or email [email protected].

CONTACT US

For general questions or inquiries, contact us Monday to Friday, 7:45AM to 4:30PM:
Call: 800-508-2222 | TTY/TDD: Dial 711 first
Email: [email protected] 
Fax: 802-657-4208