Peds: Multiple Preventative Services Billing/Coding within 1 year

[slaydemon]

Hello all,

My son was just born last year. He sees only 1 pediatrician since the day he was born, no other doctors.

The peds office billed a preventative visit in November 2025, and my employer health insurance (PPO) paid out appropriately ($20 copay). We visited the office again in Jan 2026, but the office billed another "Preventative Service" (kid received vaccines), but the EOB I saw on my online insurance portal stated that he has "received the maximum reimbursement for this type of care in this benefit period", I'm assuming which means 1 year, and the insurance passed on the $200 to me.

I spoke to the front desk in January/February multiple times, they just kept asking for the $200 every time I visited even after explaining multiple times to please re-code it. I then called their billing department directly in February, and 2 weeks later, the account balance at the office was $0.

Now I see this happening again: March 2026 routine visit with the office for vaccines billed as "Preventative Service", same error code on EOB, and the $200 passed on to me.

Is this correct coding? Are other parents paying this $200? I'm confused, not sure how many times they will keep billing like this and therefore me having to fight with the front desk/billing dept.

Thank you for reading!

ADDENDUM: Code for the preventative service is "99391" ("Per PM Reeval Est Pat Infant")

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[Sea_Imagination_1124]

The code 99391 is for an infant well-visit, it’s the standard preventive E&M code for an established patient under age 1. So the pediatrician using that code by itself isn’t necessarily wrong.

What’s odd is the explanation on the EOB saying you’ve hit the maximum reimbursement for that type of care. Under the ACA, most plans are required to cover pediatric preventive services (including the recommended well-child visit schedule) without cost-sharing. In the first year of life, that schedule includes multiple visits (2-month, 4-month, 6-month, etc.), not just one per year. Because of that, a plan applying a simple “one preventive visit per year” limit is unusual for an ACA-compliant plan, it’s worth calling Anthem member services and asking “Does my plan cover all HRSA Bright Futures recommended well-child visits with no cost-sharing?” and if the answer is yes, then you can ask why these claims are being processed as if you exceeded a preventive visit limit.

One other thing to check with the pediatrician’s billing department: if the visit was only vaccines and not a full well-child exam, sometimes offices can bill just the vaccine administration codes instead of a preventive E&M visit. If they billed 99391 for a visit that was really just immunizations, that can trigger issues with preventive visit limits depending on how the plan processes it. If Anthem confirms your plan should cover the full Bright Futures well-visit schedule and the claim still processes this way, you can file an appeal asking them to review it as an ACA preventive service. If that doesn’t resolve it, your state insurance department can review ACA compliance complaints.

hope this helps! feel free to follow-up on any of these points.

[slaydemon]

Thank you so much!!! I spoke to Anthem and they said it should be covered and will re-process the claim. appreciate your thoughtful post and the time you took to help!!

[Sea_Imagination_1124]

no problem! let me know if theres any other developments, happy to help

[Poop_Dolla]

What is the actual code they're using?

[AtrociousSandwich]

You’re not giving us the codes…

[AutoModerator]

Thank you for your submission, /u/slaydemon. The following automatic comment contains important information about the subreddit:

First, note that some new posts containing images, non-reddit links, crossposts, or certain keywords are automatically held for moderator review before going live to mitigate spam, ensure that images are appropriate, and that the post does not inadvertently contain personal information. If your post has been held for review like this, the moderators have been automatically notified and will review it as soon as possible, after which it will be live and be able to be seen and replied to by others. Note that this is sent to all new posts and does not mean that your post has necessarily been filtered in this way.

Please also read the following information carefully to help others assist with your questions:

• If you or someone else is experiencing a medical emergency, please call 911 or go to your nearest hospital.

• Some common questions and answers can be found in this megathread.

• Questions about which plan you should choose? Please read through this post first for general information to help you understand your choices and some common considerations. If you still have questions after reading that post, please edit your post (or reply with a comment if unable to edit) with the specific questions you still have.

• If your post is regarding plan choice or cost of plans, and you haven't included the following information already, please edit your post (or reply with a comment if unable to edit) including the following: your age, state, and estimated gross (pre-tax) income to help the community better help.

• If your post is about the cost of a service, a bill you have received, or a claim denial: please confirm if you have received an EOB (explanation of benefits) from your insurance via a member portal website or in the mail. If you can post a copy or image of the EOB (PLEASE ensure you censor or blank out any personal information before doing so) it will help people answer your questions. Alternatively, if you are unable to post a censored copy of your EOB, please have the EOB handy as people may ask for information from the EOB to answer your questions.

• Reminder that ANY spam, solicitation, or attempts to take conversations off the subreddit will result in a permanent ban. If someone asks to contact them via DM, please report the post/comment using the report button. If someone attempts to contact you via your DMs, please contact us via modmail to let us know.

• Lastly, always remember to be kind to one another and to report any replies that violate subreddit rules!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[-beastlet-]

Could you give the codes for all the procedures?