Key Pediatric Updates and Reminders for Well-Visits

May 22, 2025

We would like to inform you of several important updates and clarifications regarding well-visits and related services.

Key Updates and Reminders

  • No Telehealth for Well-Visits:
    • Effective January 1, 2025, telehealth services are no longer allowed for well-visits. All well-visits must be conducted in-person to ensure comprehensive care and adherence to clinical guidelines.
  • Clarification on Timing Requirements for W15 and W30 Visit Reimbursement:
    • Under 24 Months: There are no time restrictions for billing and reimbursement of well-visits for children under 24 months.
    • 1-Year Well-Visit: The 1-year well-visit should be scheduled on or after the child’s first birthday to align with the vaccine schedule and clinical best practices.
  • Sports Physicals vs. Well-Child Visits:
    • Sports physicals are distinct from well-child visits. While both are important, they serve different purposes and should be billed accordingly.
  • Sick Visits and Well-Child Visits on the Same Date:
    • Sick visits and well-child visits can be conducted on the same date of service. This allows for efficient use of time and resources while ensuring comprehensive care.
  • Annual Child and Adolescent Well-Visits:
    • Well-visits can be conducted once per calendar year, even if 365 days have not yet passed. This annual visit is crucial for monitoring the child’s growth, development, and overall health. Providers will be reimbursed as long as it is a new calendar year.

Best Practices

The following tips and strategies can help your practice ensure members are seen for necessary well-visits and closing gaps in care:

  • Combining Visits: If a patient comes in for a sick visit or sports physical and is due for a well-care visit, try to complete all services of a well-care visit during that time.
  • Outreach Efforts: Prioritize outreach by targeting patients within the same household to achieve a greater impact.
  • Comprehensive Care Gap Closure: Review all open care gaps for the patient and attempt to close them during the visit. Care gaps can be found on our provider portal.

Please note that these are recommendations only. For further guidance, kindly consult with your billing and compliance departments.

For more information on well-visits, vaccines, and improving performance, please visit our Pediatric Care Information page. The page has tip sheets, resource guides, policies, news updates, and more for our provider partners.

We appreciate your cooperation and commitment to providing high-quality care to our members. If you have any questions or need further assistance, please do not hesitate to contact us.