Is a new patient teen physical covered by insurance?
Usually yes, at the same preventive benefit an established patient gets. A new patient teen checkup (code 99384) is the first full exam for a 12 to 17 year old at a practice that has not seen them before. The catch is the plan's one checkup a year, which may already be spent at the old office.
Same benefit
New patient, same preventive rules
Three year rule
New patient means no pediatrician in the group has seen the teen in three years. If a partner did, the visit is an established one, 99394, at a lower rate.
Benefit used up
If the old pediatrician already did this year's checkup, the plan has paid its one preventive visit and the new practice gets the denial.
HMO assignment
On many HMO plans the child stays assigned to the previous doctor until the family changes it. Claims from the new office deny until that switch is made.
Check at intake
New patient paperwork is the moment to verify. One check shows whether the plan is active and what is left on the deductible before the exam happens.
What would a real check show for this patient's 99384?
Pick a sample plan and type your fee. This is the visibility a real-time check gives the desk for every actual patient, in under a second.
Eligibility readout · 99384
Sample- Coverage
- Active, new patient checkup at $0 in network
- Frequency
- One preventive visit per plan year, none used
- Patient share
- Type your fee to see it
Estimate from a sample plan. A real check reads the actual plan in under a second.
When 99384 is the right code
- Teen is 12 through 17 on the exam date
- No pediatrician in the group has seen them in three years
- It is a full checkup, not a problem visit
- Exam, history, screenings and counseling documented
Documentation payers expect
The new patient rule has to hold across the whole group and specialty, and the chart needs a full history, exam and the screenings run. Records from the old practice help when a plan questions a duplicate checkup.
Why new patient teen physicals get denied
What happens after the first teen visit
A first visit at a new practice usually starts a list. Missing shots get caught up, each with a counseling shot fee (90460) beside the product line, and the HPV series (90651) runs across two or three appointments. A mood questionnaire (96127) bundles unless the checkup line carries modifier 25. If the old office already used this year's preventive benefit, the whole exam bills to the family, which is a conversation the desk wants before the appointment.
99384, quick answers
Does insurance cover a checkup at a new pediatrician?
Usually yes, at the same preventive benefit. Most plans pay 99384 at 100% in network as long as the one checkup a year has not already been used.
What makes a patient new?
No face to face service from a physician or other qualified professional of the same specialty and subspecialty in the same group in the last three years. Otherwise the established patient code applies.
The teen had a physical at the old office in January. Now what?
Most plans will not pay a second preventive visit the same year. The exam can still happen, billed to the family or scheduled after the benefit resets.
Does Medicare pay 99384?
No. Medicare's preventive benefit is limited to its own wellness visit G codes for adult beneficiaries, so 99384 has no Medicare equivalent.
When should a new patient be verified?
Check at booking and again the day before, since the result carries plan status, remaining deductible and out of pocket, and any referral flag the payer reports, saved to the patient. First month free, then $2.50 a check.
More questions? Schedule 15 minutes with us and bring your toughest plan.
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Related: 99394 · 99382 · 99385
CPT is a registered trademark of the American Medical Association. This page is Valian's own plain-English summary for front-desk teams, not official CPT descriptor text, and is not billing or clinical advice. Coverage patterns are common plan behaviors; every plan differs. Verify benefits before the visit.