Welcome to the Missouri Show Me Healthy Women (SMHW) and Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) programs offered through the Missouri Department of Health and Senior Services (DHSS). The purpose of the SMHW and WISEWOMAN Provider Manuals is to help participating health professionals understand program requirements and provide services to program-eligible women.

This manual is intended to offer an integrated approach in providing SMHW and WISEWOMAN services. It is designed to provide important information needed to enroll clients into the SMHW and WISEWOMAN programs, explain health professional roles and responsibilities, define reimbursable services, and provide necessary reimbursement and billing information. It also includes a framework for clinical guidelines to adhere to program standards. The SMHW and WISEWOMAN staff are available to assist providers on a regular basis using e-mail, telephone, and on-site visits as needed. Help is available by calling toll-free at 866-726-9926 or 573-522-2845.

Show Me Healthy Women Vision and Mission

Vision Statement

Improve the quality of life in Missouri through the cure and elimination of breast and cervical cancers.

Mission Statement

Support quality screening, diagnostic and treatment services, in accordance with current medical standards of care, for breast and cervical cancers for all women in Missouri. This is achieved by education, community outreach, and resource development in partnership with public and private entities, communities, and citizens.

WISEWOMAN Vision and Mission

Vision Statement

A world where any woman can access preventive health services and gain the wisdom to improve her health.

Mission Statement

Provide low-income, underinsured or uninsured, 35–64-year-old women with the knowledge, skills and opportunities to improve their diet, physical activity and other life habits to prevent, delay or control cardiovascular and other chronic diseases.

History

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

http://www.cdc.gov/cancer/nbccedp/

The United States Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354) to establish the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The Centers for Disease Control and Prevention (CDC) authorizes the NBCCEDP to provide grants to states, American Indian/Alaska Native tribes, and U.S. Territories to carry out cancer early detection activities.

WISEWOMAN

http://cdc.gov/wisewoman

Congress amended the NBCCEDP Public Law 101-354 in 1993 to create the WISEWOMAN Program. The WISEWOMAN Program addresses women’s risk for heart disease and stroke by providing cardiovascular disease health screenings and risk reduction lifestyle education for NBCCEDP clients.

NBCCEDP and WISEWOMAN Similarities

NBCCEDP shares an established infrastructure with WISEWOMAN to provide integrated services including:

• Recruiting and working with women eligible for services
• Delivering screening services through an established healthcare delivery system
• Collecting and reporting minimum data elements (MDEs) used to track, monitor and evaluate program efforts
• Providing professional development opportunities for staff, providers and partners
• Providing public education to raise awareness about the need for women to receive program services
• Assuring that quality care is provided to women participating in the program

At-A-Glance

Comparison of NBCCEDP and WISEWOMAN

Contractual Agreements

The SMHW program utilizes contracts with service providers to deliver program services. Contracts are available for SMHW-only services or for providers who choose to deliver both SMHW and WISEWOMAN services.

What We Do

• Establish annual contracts for screening providers
• Provide an easily accessible program manual that describes screening, follow-up, education, and reporting guidelines based on national CDC guidelines
• Require providers to utilize Clinical Laboratory Improvement Amendments of 1988 (CLIA) approved laboratories or ensure laboratory equipment is CLIA-waived
• Provide Regional Program Coordinators (RPCs) for each geographic region to assist providers with training, technical assistance, and tracking clients with abnormal values to ensure clients receive appropriate follow-up
• Provide training and technical assistance to provider staff
• Provide client recruitment targeting ethnically diverse program-eligible women
• Provide client educational materials and tools
• Provide required reporting forms and a data system for submitting service reports
• Reimburse providers for allowable services according to Medicare 01 region rates
• Monitor provider services to assure quality standards
• Maintain a central data system for tracking and reporting required data to CDC
• Assist service providers with client case management/follow-up and annual evaluation screening efforts
• Provide promotional items, literature, and other public educational materials when available

Show Me Healthy Women Advisory Board

The SMHW Advisory Board strengthens the program’s activities in the state of Missouri through professional and policy development, public and clinical education, private partnerships, and coalition building.

Advisory Board Responsibilities

• Advise SMHW management on SMHW issues
• Assist SMHW in enhancing the breast and cervical cancer control knowledge and skills of Missouri’s healthcare professionals
• Assist SMHW in identifying appropriate breast and cervical cancer control legislation
• Establish task forces, as necessary, to assist SMHW in developing cancer control policies, such as cervical and breast cancer screening protocols and policies, diagnostic guidelines, and funding applications
• Assist SMHW in identifying partners who will extend and enhance the work of SMHW

The SMHW Advisory Board is composed of representatives of organizations that are, or potentially can be, involved in SMHW activities and of individuals with special expertise in breast and cervical cancers. The board has approximately 30 members. Elected board members serve a two-year term. The Board meets quarterly and meetings are open to the public.

Provider Contract Requirements

All of the following provider contract requirements must be met.

Complete SMHW/WISEWOMAN Information Update Form

Complete and sign the SMHW-WISEWOMAN Information Update Form annually. The SMHW/WISEWOMAN Information Update Form is located here.

Recruit Clients

Recruit clients by the following activities:

• Utilize public education resources provided by DHSS to recruit eligible women
• Collaborate with the American Cancer Society (ACS), National Cancer Institute (NCI), American Heart Association (AHA), local cancer control coalitions, and other local partners
• Display recruitment and educational information in waiting areas and examination rooms
• Provide materials on screening services to all eligible women attending clinics in the facility
• Coordinate recruitment activities with the DHSS staff and the designated area RPC
• Schedule women for annual screenings at a minimum of 10-month intervals following the initial or annual screening
• Recruit WISEWOMAN clients from SMHW clients

Attend Training

• Attend SMHW/WISEWOMAN provider staff training
• New providers of SMHW/WISEWOMAN services must participate in an on-site training session by DHSS staff prior to providing services
• Ensure staff is well trained in program protocols prior to delivering services. Require at least one staff member to participate in an orientation training delivered by DHSS program staff upon initial contract application
• Facilitate attendance/participation of staff members responsible for submission of data forms and clinical services at annual trainings that provide policy and procedure updates and review
• Request DHSS training sessions when new staff are hired

Register Clients for Services

• Obtain clients’ signatures on the SMHW-WISEWOMAN Client Eligibility Agreement Form.
• Annually provide clients with the current DHSS patient privacy rights statement in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations prior to receiving services annually. The client must receive this information along with the HIPAA statement from the provider facility. The provider must retain documentation of this action.

Comply with HIPAA Regulations

• Comply with current HIPAA regulations in delivering services.

Utilize Medical Staff

• Provision of services is dependent upon current license or certification with the State of Missouri.
• Utilize medical doctors, doctors of osteopathy, nurse practitioners, certified nurse midwives, clinical nurse specialists, certified physician assistants, and registered nurses (RNs) with specialized training within the registered nurse’s scope of practice to provide services.

Obtain Permission for RN to Provide Services

Obtain written approval from DHSS for the RN to provide breast and cervical screening services for SMHW clients. Submit the following information in a written request to SMHW:

• A letter documenting previous practice;
• A licensure or certification numbers; and
• Documentation of any of the following breast and/or cervical cancer screening training:
  • Length of the preceptorship;
  • Number of pap tests, CBEs, and pelvic examinations completed during the preceptorship. A minimum of 10 pap tests, CBEs, and pelvic examinations must be performed in order for the RN to be eligible to provide screening services; and
  • The preceptor must verify that the nurse completed these examinations with minimal or no difficulty.

Laboratories

Utilize only laboratories that adhere to all applicable standards established under the Clinical Laboratory Improvement Amendments (CLIA) of 1988 or are CLIA waived. Laboratories must report pap test findings using the Bethesda System 2001.

MQSA

Comply with Mammography Quality Standards Act (MQSA). Prior authorization by SMHW and DHSS is required for MQSA-accredited mobile mammography vans based out-of-state.

Report Results – Mammography

Report mammography test results in the American College of Radiology BIRADS system.

On-Site Quality Assurance Reviews

Agree to on-site record reviews by qualified DHSS staff six months after initial services begin and every two years thereafter, or more frequently if requested by the DHSS.

Notify Clients

Notify clients of non-program-covered services. Notify the client in writing of any services not covered by the programs prior to providing any non-program-covered services.

Billing Clients

Ensure clients receive no bills (invoices) for services covered by the SHMW or WISEWOMAN programs.

Electronic Data and Reports

Enter all data and reports electronically with accompanying Current Procedural Terminology (CPT) codes into the SMHW central data management computer-tracking program, Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC).

Reporting Form

Submit a fully completed reporting form within 60 days of the last date of service. An exception should be noted for end-of-grant-year services. The end-of-year billing deadline notification is sent to providers annually.

Electronic Reimbursement

Agree to receive SMHW/WISEWOMAN reimbursements through Electronic Fund Transfer (EFT). SMHW/WISEWOMAN reimbursement rates and CPT codes can be viewed in Section 9; Billing Guidelines.

Recording and Maintaining Documentation

Complete and maintain documentation on all client eligibility, screening, and case management services outlined in this manual. Maintain client records for at least seven years. All SMHW enrolled clients with an abnormal screening result must be assessed for their need of case management services and provided with such services accordingly. Examples of screening results which would require a case management assessment would be BIRADS 3, 4, 5 for mammograms; and Atypical Squamous Cells of Undetermined Significance (ASCUS), Low-grade Squamous Intraepithelial Lesion (LSIL), and high grade lesions for pap tests. Case management services conclude when a client initiates treatment, refuses treatment, or is no longer eligible for the SMHW program. When a woman concludes her cancer treatment, and is released by her treating physician to return to a schedule of routine screening, she may return to the program and receive services if she meets eligibility requirements.

Assure Follow-up

Assure all clients identified on screenings that have suspicious, abnormal, or alert test results receive appropriate follow-up services, including case management, rescreen, diagnostic evaluation, treatment referral and/or education services according to program protocols. These services may be provided directly by the contracted provider or by an established referral sub-contractor that meets SMHW/WISEWOMAN program requirements. All test results shall be maintained in the client’s medical records for monitoring purposes.

Communicating with Sub-contractors

Ensure that communications with sub-contractors include notification and approval from the SMHW/WISEWOMAN provider prior to the subcontractor’s provision of additional tests. This communication is necessary to be sure the subcontractor’s services and reimbursements will meet SMHW/WISEWOMAN program guidelines. Providers are also responsible for ensuring that clients understand why they are being referred and what services will be provided. It is the recommendation of DHSS that a written agreement between each sub-contractor and each SMHW/WISEWOMAN provider is complete.

Subcontractor Requirements

Ensure subcontractors meet the requirements specified in these guidelines (i.e., MQSA, CLIA, etc.). Subcontracted services may include:

Refer Tobacco Users

Ensure that SMHW and WISEWOMAN clients who use tobacco products are referred to the Missouri Tobacco Quit Services 800-QUIT-NOW (800-784-8669) for free counseling. The Missouri Tobacco Quit Services is available free of charge to all Missouri SMHW and WISEWOMAN participants. Be sure to have the client complete a fax referral form and fax the form to the Quitline.

Submit Personnel Information

Submit written changes of clinical, administrative and personnel contact changes to DHSS within 30 days.

Collaborate

Collaborate with the Missouri Department of Social Services (DSS) , Family Services Division (FSD) regarding clients diagnosed with breast/cervical cancer. These clients may be eligible for treatment through the Breast and Cervical Cancer Treatment (BCCT) Act.

Providers Who Terminate Participation

Submit Letter

Submit a letter to DHSS 30 days before the date of anticipated termination of services. The letter must include the date of termination of SMHW/WISEWOMAN services.

Continue to Report

Continue to report all diagnostic and/or treatment information after termination on the appropriate SMHW/WISEWOMAN forms to complete all outstanding follow-up cases. To accomplish this, a provider should work closely with the Regional Program Coordinator (RPC) in their area.

Work with RPC

Work with the RPC to inform clients where they may obtain SMHW/WISEWOMAN services in their area once the provider terminates participation.

Provider Application Approval Criteria

The DHSS approves or disapproves providers based on the following criteria:

Commitment

Commitment and ability to meet the contract requirements

Accreditation

Accreditation or certification status of the site and clinical staff

Capacity

Capacity to submit timely and accurate data and billing reports to DHSS via the MOHSAIC electronic reporting system

Location

Located in area of need in relation to other SMHW/WISEWOMAN providers and to the population to be served

Commitment to Clients

Commitment and ability to serve clients with special emphasis on priority-eligible populations, particularly women 21-64 years of age or older and women who have rarely or never been screened

Experience

Successful experience in providing comprehensive breast and cervical cancer screening, education and referral services, either through existing on-site facilities or referral linkages. Access to CLIA-approved laboratory and/or MQSA accredited mammography facility

Network

Ability to network with the ACS and NCI, and other educational state and regional resources

Compliance

Compliance with current HIPAA regulations; and

Application Denial

If an application is denied, a contact list identifying other SMHW/WISEWOMAN providers in the same geographic area will be provided. Applicants may use this information to facilitate referrals for women in need of SMHW/WISEWOMAN services.

The Provider Application can be found here.

Client Eligibility Guidelines

SMHW eligibility has three primary criteria: income level, health insurance status and age guidelines. Income guidelines are based on 250 percent of the federal poverty guidelines. The SMHW program reimburses only for services when there is no other funding source available. Women 21 to 64 years of age are eligible for services; some service restrictions apply by age category.

SMHW/WISEWOMAN Programs are the payors of last resort. Providers may call the program RPC for guidance.

Age Eligibility Includes 21 to 64-year-old Women

Some exceptions pertain to guidelines for services available to clients older than 64 based on insurance. Please see page 3.3 for further information.

Transgender Clients

• Screening and diagnostic services are available for male-to-female transgender clients who have/are taking hormones as long as they meet program eligibility guidelines.
• Screening services are available for female-to-male transgender individuals who have not yet undergone a complete hysterectomy or bilateral mastectomy because these individuals are genetically female.
• The CDC does not make a recommendation on routine screening with this population; transgender women are eligible under federal law to receive appropriate cancer screening.
• To determine the medical necessity of screening, the CDC recommends providers discuss the risks and benefits of screening with all eligible clients.

Income Guidelines

Clients must have an income at or below 250 percent of the federal poverty income guidelines. Adjusted gross income on tax return or net amount on pay stub determines income eligibility.

Insurance Status of Uninsured or Underinsured

Providers may use the Client Eligibility Agreement form to document the insurance status of the client. Copies of these forms are located on pages 10.6-.7, or download a copy here.

Current Breast or Cervical Cancer

• Women who are currently diagnosed with a breast and/or cervical cancer are not eligible for SMHW services. Women being currently treated for breast or cervical cancer are also not eligible for SMHW services. However, once cancer treatment is completed the client may return to SMHW for routine screenings as long as eligibility guidelines are met.

MO HealthNet (Medicaid)

• Women with MO HealthNet Managed Care coverage may be eligible for SMHW services if they are enrolled in the Extended Women’s Health Services/EWHS, Uninsured Women’s Health Services/UWHS, or have an unaffordable MO HealthNet spend-down. These women are eligible for screening/diagnostic services through SMHW. Extended Women’s Health Services/EWH’S and Uninsured Women’s Health Services does not cover diagnostic services. The woman must meet all SMHW eligibility guidelines.
• SMHW Clients who reach age 65 and older or women previously not enrolled age 65 and older do not qualify for BCCT.

Medicare

• Women enrolled in Medicare Part B are not eligible for SMHW services. Medicare Part B covers breast and cervical cancer screenings. Refer women with Medicare Part B coverage to providers who accept Medicare reimbursement.
• Women who meet SMHW/WISEWOMAN eligibility requirements and state they cannot pay the premium to enroll in Medicare Part B, or are not eligible to enroll in Medicare Part B, are eligible for SMHW/ WISEWOMAN screening services. If women are eligible to receive Medicare Part B benefits and are not enrolled, encourage them to enroll.

Insurance

• The client’s insurance must be billed first; when billing DHSS, include the insurance payment amount on reporting forms in the “Comments” section. SMHW will only reimburse up to the total amount allowed for the procedure per program guidelines. The total amount allowed and reimbursed by SMHW for each CPT code includes any payments received from insurance companies, not in addition to insurance payments.
• SMHW and WISEWOMAN are the payors of last resort.
• Women enrolled in prepaid/managed care and health plans (such as Health Maintenance Organizations [HMOs], Point of Service Plans [POS] and MO HealthNet Managed Care [formerly MC+]) are not eligible for SMHW/WISEWOMAN services.

For further guidance regarding clients with insurance, please see page 9.3.

Documentation and Certification of Client Eligibility

The client must sign a SMHW Client Eligibility Agreement form that is retained in the client’s record each year. (Download a copy of this form here or pages 10.6 [English] and 10.7 [Spanish])

Providers must obtain documentation of income, age eligibility and address, if available, on an annual basis and place a copy of the documentation in the client’s record. (Electronic or paper medical records are acceptable.)

Once eligibility is determined, screening providers must verify eligibility on all reporting forms. To comply with the quality assurance policy, 50 percent of client records must contain proof of eligibility.

Provider must retain information in clients’ charts regarding the green history form, (pages 10.8 [English] and 10.9 [Spanish] or here, and review this information with each additional annual screening. Client records must be retained and available for seven years.

Free Transportation for Clients

Free transportation is available for SMHW/WISEWO MAN clients. Providers can request a travel voucher booklet by contacting Show Me Healthy Women/WISEWO MAN staff or the Regional Program Coordinator ( RPC) assigned to their area. All program services qualify for transportation services, including initial office visits, lab visits, follow - up diagnostic office visits, lifestyle education sessions, and annual evaluation screenings in the contracted counties.

Travel Voucher Instructions

Funds are available through SMHW and WISEWOMAN to cover the cost of transportation to help remove the barrier of access to care in receiving screening, diagnostic, and education services.

Transportation services are available in most counties and St. Louis City. Please call the RPC for assistance. See pages 3.8 and 3.9 for a complete list of transportation providers and their contact information. Services are available Monday through Friday, with charges based on urban or county trips and one-on-one or regular-route travel. When a client calls to make an appointment for a SMHW or WISEWOMAN screening or diagnostic, or education services, please ask her the following questions before making an appointment date and time for her:

Does the client need transportation?

If yes, explain that free transportation is available for SMHW participants. A transportation provider will pick her up at her home, take her to the appointment, and return her to her home. Check with the transportation provider in your area for the transportation schedule. Ensure the client’s appointment date and time coincide with the transportation provider’s schedule.

Secure client address and telephone number.

If the client does not have a telephone, ask for a neighbor’s telephone number or for another number where she can be reached. The transportation driver may not be familiar with the client’s address and may need directions to the residence.

Does the client need any special assistance?

If the client needs an assistant or helper, SMHW will pay for transportation for one extra person. The assistant or helper should be 17 years of age or older. If a disabled client needs more than one assistant, call SMHW for approval. If the client has special medical equipment such as a wheelchair or oxygen, please inform the transportation provider at the time of scheduling.

Travel Vouchers

Complete the travel voucher and include the facility name and site code number. The provider can mail or fax the completed travel voucher to the transportation provider including the date and time of the appointment. A copy of the voucher may be given to the client. The transportation provider will secure the client’s signature on pickup.

Cancellation

Notification of cancellation to the transportation provider is required to avoid a penalty charge to SMHW/WISEWOMAN for the cost of the round trip. Provide a one business-day notice to cancel a trip. Contact the transportation provider for questions related to transportation services. See page 3.8 and 3.9 for a complete list of transportation providers, service areas, and contact information. Address SMHW questions to the central office by calling toll-free at 866-726-9926 or 573-522-2845.

Screening Recommendations

Routine screening and early detection are vital to reducing morbidity and mortality from breast and cervical cancer. Regular screening and early detection decreases mortality and improves quality of life for all individuals. Regular clinical breast exams, mammography, pelvic exams, and pap tests are the best screening methods available for breast and cervical cancers and pre-cancerous conditions.

Provider Responsibilities

• Schedule annual breast and cervical cancer screenings appropriately for clients.
• Notify clients in advance of recommended screening dates. If the client does not schedule an appointment after the first notification, a second attempt shall be made.

Initial Screening

The initial screening is:

• The first screening performed on a woman by a SMHW provider.

OR

• If a client has not been seen for five years for a SMHW screening by the same provider.

Annual Screening

The annual screening is:

• The process of returning for an annual screening test at a predetermined interval. SMHW defines an annual screening to be 10 months or greater from the initial screening.

Rescreening

Rescreening is:

• An additional screening visit resulting from an abnormal initial or abnormal annual screening that is less than 10 months from an initial or annual screen.

Green History Form

All forms are annually associated with their specific grant year. When submitting an electronic or a paper form, use the version of the form that is the grant year which corresponds with the date of service. At the beginning of each grant year, there are multiple versions of this form available in Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC). Click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner: example (3/14).

• Information from the green history form is used to verify a client’s eligibility for screening, as well as statistics to evaluate the program. Some information from the green history form is also reported to the Centers for Disease Control and Prevention (CDC). Keep all information confidential.
• The information on the original form shall be entered electronically in the MOHSAIC system. File all reported information in the client’s record.
• Access MOHSAIC electronic forms at this link.
• A copy of the green history form is located on page 10.8 [English] and page 10.9 [Spanish] or download a copy here.
• If you have additional questions, please call SMHW toll-free at 866-726-9926 or 573-522-2845 for general assistance with central office staff.

If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

Clinical Requirements for SMHW Services

The screening services outlined in the following pages are clinical requirements and shall be completed by the provider of SMHW services in order to be considered for reimbursement. Age restrictions and income guidelines always apply. Providers must have the capability to provide or offer access to the following services:

Comprehensive Breast and Cervical Screening

• Clinical Breast Exam (CBE) provided annually for all women
• Assessment for High Risk for breast and cervical cancer
• Client education on the importance of obtaining screenings for breast and cervical cancer according to the appropriate screening schedules
• Routine screening mammogram offered annually or every other year per clinician and client determination, beginning at age 40 and over. (Table 1, page 4.6):
• Special circumstances include:
  • Offer a mammogram annually if a woman has a personal history of breast cancer
  • Any client, age 21 or older, who currently has abnormal breast exam results, can receive diagnostic mammograms and other necessary breast diagnostic services covered by the SMHW program
• Complete visual and manual pelvic examination
• Pap test, conventional or liquid-based, HPV test at appropriate intervals (Table 2, page 4.7)
• Documentation of providing screening examination results to clients per verbal report or in writing
• Appropriate and timely case management for all clients with suspicious or abnormal results, including rescreening, diagnostic procedures and/or treatment

Annual Screening Protocol

Age restrictions and income guidelines always apply to a client’s eligibility for the services described below.

Breast Cancer Screening

• A Clinical Breast Exam (CBE) is recommended by SMHW for a complete screening and is a reporting requirement of the grant. Coordination of a full screening with health care providers is expected. Perform a CBE annually, as needed, on all women, especially if they have had previous breast cancer surgery.
• CBE is not required for reimbursement of a mammogram. Provide an annual mammogram to clients with a personal history of breast cancer at the clinician’s discretion.
• SMHW will reimburse for an annual breast cancer screening after ten (10) months have lapsed from the previous annual breast cancer screening. This includes annual CBE for all SMHW women ages 21 to 64 and yearly or every other year screening mammograms for women ages 40 and older. (Refer to Table 1, page 4.6)
• Family history of breast cancer does not qualify a woman for routine mammograms.
• A client with self-reporting abnormal breast self-exam (BSE) may be followed with a diagnostic breast work-up, except for self-reporting pain and tenderness or family history. If pain and tenderness are self-reported, she may be followed with a rescreening CBE in two (2) weeks up to 10 months. If the client continues to report pain and tenderness, case management is at the clinician’s discretion.
• (Diagnostic workup may include services such as diagnostic mammogram, ultrasound, specialist consult and breast biopsy.)
• Mammogram funding to screen women 40 to 49 years of age without abnormal breast findings through SMHW is available per clinician discretion.
• Women 21 years of age and older qualify for diagnostic breast services if breast exam findings are abnormal.

Magnetic Resonance Imaging (MRI)

• ALL SCREENING MRIs MUST HAVE PRIOR AUTHORIZATION from the SMHW program manager. Contact your RPC with client information for approval from the manager.
• SMHW will pay for a screening breast MRI to alternate with a screening mammogram and documentation of one of the following:
  • BRCA mutation
  • A first-degree relative who is a BRCA carrier
  • A lifetime risk of 20–25% or greater as defined by risk assessment models such as BRCAPro, Tyrer-Cuzick or the Gail Model (as they are highly dependent on family history)
• The CDC suggests providers discuss risk factors with all clients to determine if they are at high risk for breast cancer
• MRI should NEVER be done alone as a breast cancer screening tool
• Breast MRI cannot be reimbursed to assess the extent of disease in clients who have already been diagnosed with breast cancer
• To be most effective, it is critical to complete MRIs at facilities equipped with breast MRI equipment and perform MRI-guided breast biopsies

Annual Breast Recommendations for Women

High Risk for Breast Cancer

• BRCA mutation.
• A first-degree relative who is a BRCA carrier.
• A lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO, Tyrer-Cuzick or the Gail Model as they are highly dependent on family history.

Cervical Cancer Screening

• Pap test results of “inadequate specimen” are not reimbursable by SMHW.
• Pap test results initially indicating no endocervical cells should refer to ASCCP guidelines.
• For women who have a cervix, pap tests will be covered every three (3) years if no human papillomavirus (HPV) done, or screening with a combination of a pap test and HPV testing every five (5) years. See Screening Report Form (pages 10.10-.11).
• Hysterectomy:
  • SMHW will NOT fund pap testing for women who had a hysterectomy for benign (non-cervical neoplasia) conditions. A woman who has no cervix due to a reason other than cancer may have a pelvic exam to establish that there is no cervix.
  • Follow a woman annually for 10 years (conventional or liquid-based pap tests can be reimbursed) if reason for hysterectomy is unknown or if it was for cervical intraepithelial neoplasia (CIN) CIN 2, CIN 3, adenocarcinoma in situ (AIS) or cervical cancer in situ, which was biopsy-documented.
  • Women who had a hysterectomy for invasive cervical cancer should undergo an annual pap test (conventional or liquid-based) annually; or perform HPV testing or Pap/HPV co-test every three years indefinitely as long as they are in good health.
  • Annual pap test maybe done only for persons who meet specific high-risk guidelines for cervical cancer per CDC and/or SMHW Advisory Board approval.

Annual Cervical Cancer Screening Recommendations for Women*

Cervical Cancer Risk Factors to Consider

Risk factors which are NOT adequate to warrant annual pap screening:

Blue Screening Form

All forms are annually associated with their specific grant year. When submitting an electronic or a paper form, use the version of the form that is the grant year, which corresponds with the date of service. At the beginning of each grant year there are multiple versions of this form in MOHSAIC (page 10.10-.11). Be sure to click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner: example (3/14).

• Information from the blue screening form is used to verify clients’ eligibility for screening, as well as diagnostic services that are recommended. Some information from the blue form is reported to the CDC. Keep all information confidential.
• The information on the original form shall be entered electronically in the MOHSAIC system. File all reported information in the client’s record.
• Access MOHSAIC electronic forms at this link.
• A copy of the blue screening form is located on pages 10.10-.11 or download a copy here.
• If you have additional questions, please call SMHW toll-free 866-726-9926 or 573-522-2845 for general assistance with central office staff.
• If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

SMHW Clinical Service Summary

A mandatory component as a provider of the SMHW program is the responsibility for providing clinical case management of abnormal findings as well as reporting the abnormal findings, and the outcomes to the SMHW program on a timely basis.

The clinician, using current standards of practice and the established SMHW breast cancer screening protocols, determines abnormal findings clinical case management type and frequency.

Provider Assurances

Providers Must Ensure the Following

Suspicious or Abnormal Breast Results

Clients with suspicious or abnormal breast results will receive the necessary case management as determined by the clinician based on current standards of practice for rescreening, diagnosis, and/or appropriate treatment. Clinicians will report data to SMHW. To meet the program requirements, two diagnostic tests must be completed after an abnormal CBE. In the event a second diagnostic test is not completed, include a detailed comment in the comment section of the breast (purple) form as to why a second diagnostic test was not completed.

CDC - 60 days or less from result of suspicious for cancer screening to diagnosis.

Standard - 60 days or less from time of cancer diagnosis to start of treatment.

Determination of Screening Results

Suspicious screening results will be determined as normal or abnormal through short-term rescreen or diagnostic procedures.

• Notify and explain to the client with abnormal findings the need for any additional diagnostic service(s).
• SMHW requires two documented attempts for client follow-up, if needed.
  • Direct telephone communication is the most effective contact.
  • If unable to reach client by telephone, a letter should be sent indicating there is need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.
  • If no response is received after the second attempt or the client refuses further diagnostics and/or treatments, notify your RPC.

Pending Abnormal Screening Results

If abnormal screening results are pending for ten (10) months or longer, client eligibility must be re-checked and a new annual screening test must be performed before the initiation of further diagnostic studies. SMHW will only reimburse for additional diagnostic services if the client continues to meet SMHW eligibility guidelines.

• For clients referred to direct billing diagnostic providers (page 9.5), continue to track that the client receives/attends the scheduled appointments.
• For a client diagnosed with cancer, SMHW providers must provide the following information to SMHW:
  • Date treatment started
  • Type of treatment initiated
  • Name of the facility where treatment occurred

Rescreen Protocol

CBE

• For the first occurrence of breast pain and tenderness, SMHW will only reimburse for an office visit for the CBE. SMHW does not reimburse for breast diagnostics for the first occurrence of breast pain/tenderness.
• A rescreen CBE can be performed after 14 days or within 10 months of an initial CBE with the first time reported pain/tenderness. Please see page 5.10, condition number four (4).
• A repeat CBE is an option as a rescreen, performed 14 days to 10 months after a CBE deemed suspicious for cancer and after the performance of appropriate diagnostic test confirms non-cancer diagnosis. If no prior SMHW documentation is submitted, it is acceptable to enter the first occurrence of pain/tenderness in the comments section of MOHSAIC.

Mammogram

• SMHW will pay up to four consecutive probable benign mammograms within two years. The standard recommendation for a probable benign mammogram is four consecutive six-month follow-ups (a complete cycle of two years). However, if during this follow-up cycle the test result is downgraded to a benign finding (Category II), additional follow-up is not required. If the result remains probably benign or upgraded to a higher category, another type of additional diagnostic testing must be performed within 60 days.
• A repeat mammogram is an option within ten (10) months if the previous mammogram reported to SMHW was a “Category 0, Need evaluation or film comparison.” If “Category 0, Need evaluation or film comparison” is the result reported on a mammogram; film comparison, additional mammography, or ultrasound images are needed within 60 days. If possible, providers should not enter this result until the final result is available. However, if “Category 0, Need evaluation or film comparison” is noted on the blue screening form (pages 10.10-.11), providers should complete the film comparison or take additional images within 60 days. The film comparison result should be reported in the Comments section on the purple breast form (pages 10.12-.13) if the blue screening form has already been submitted. Additional imaging would also be reported on the purple breast form (pages 10.12-.13).

New Breast Lump

• For clients who received an annual SMHW screening that was normal, but later notes a new breast lump, SMHW will not cover the cost of the second office visit but will pay for the diagnostic testing if the CBE is abnormal. If the clinician does not find a lump and chooses to complete diagnostic testing as a result of the breast self-examination, SMHW will cover the cost of the diagnostics.

Ultrasound

• Ultrasound may be used as a rescreening tool when a mammogram is not appropriate. Rescreen must be less than ten months from original abnormal ultrasound screening.

Specialist Consultation Guidelines

A SMHW client may be referred for a specialist consultation following abnormal screening and diagnostic test results. Refer clients requiring a specialist consultation to a surgeon, OB/GYN specializing in breast and/or cervical health, or a physician or nurse practitioner who works for a cancer diagnostic or treatment center. Referral to the same screening examiner is not a specialist consult.

Specialist Consultation Reminder

• Retain a copy of the consult in the client’s chart. Do not submit a copy to SMHW.

Diagnostic Services Available

Guidelines for Breast Diagnostic Services

CBE Suspicious for Cancer

• Completely evaluate and appropriately refer women age 21 and older with a clinically suspicious lesion.

Non-palpable Mammography Abnormality

• Mammography results reported by a radiologist with reference to American Cancer Society (ACS) categories “Suspicious abnormality” (Category 4) or “Highly suggestive of malignancy” (Category 5) should be referred to a surgeon.
• “Additional Imaging Pending” (Category 0) should be followed by additional views, comparison of films and/or ultrasound within 60 days. If comparison of previous films is needed, only the final result of the comparison study should be reported. Providers who have already submitted reporting forms with the “Additional Imaging Pending” (Category 0) should enter results on the Breast Diagnosis and Treatment form in the Comments section.

Ultrasound

• Ultrasound may be recommended when the CBE is suspicious for cancer and mammogram is not appropriate.
• Abnormal ultrasound requires additional diagnostic imaging.
• Refer women whose results are Category 4 or Category 5 to the BCCT program with or without a biopsy.

Breast Biopsies:

Fine Needle Aspiration, Core Needle, Stereotactic, Incisional or Excisional

• The BSE, CBE and/or imaging mammogram/ultrasound must be suspicious for cancer and information submitted to SMHW before the program will reimburse for breast biopsies.

3-D Mammography/Tomosynthesis

• SMHW will reimburse for clients who undergo 3-D mammography (Tomosynthesis).

Flowchart - Selecting the Correct Form When Entering a Mammogram

Flowchart

Guidelines for the Management of Breast Self-Exam (BSE) Reported Symptoms

View guidelines

Guidelines for the Management of Clinical Breast Exam (CBE) Results

View guidelines

Guidelines for the Management of a “Suspicious for Cancer” CBE and First Follow-up Test is a Diagnostic Mammogram

View guidelines

Guidelines for the Management of Women Who Have Suspicious for Cancer CBE and First Follow-up Test Is NOT a Mammogram

View guidelines

Diagnostic Breast Follow-up Algorithms

View guidelines

Purple Breast Form

All forms are specific for each grant year. When submitting an electronic or a paper form, use the version of the form that is dated correctly to correspond with the date of service. At the beginning of each grant year there are multiple versions of this form in MOHSAIC. Click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner.

• The blue screening form must accompany or precede the purple breast form. A SMHW or a non-SMHW provider must base the diagnostic service on an abnormal screening result.
• Information from the purple breast form is required by CDC and is crucial for statistical reports and studies. All information received is confidential.
• The information on the original form shall be entered electronically in the MOHSAIC system. All reported information shall be filed in the client’s record.
• MOHSAIC electronic forms can be accessed at https://healthapps.dhss.mo.gov/smhw/.
• A copy of the purple breast form is located in Section 10 - Forms or download a copy online.
• If you have additional questions, please call the RPC for the provider area or toll-free 866-726-9926 or 573-522-2845 for general assistance with central office staff.
• If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

Refer to Section 10, Forms Section or follow link to forms.

Alert Value Follow-Up

The MOHSAIC electronic reporting system has been programmed to produce lists of clients and the SMHW providers who reported abnormal, suspicious for cancer results. These lists are forwarded at least weekly to the RPCs. The RPCs check the MOHSAIC reporting system to determine if follow-up is reported timely. If no information is entered into MOHSAIC regarding the necessary follow-up, the RPC will contact the provider to ensure that follow-up has occurred and that it will be reported by the provider; or, if the provider or client is experiencing difficulty in completing the follow-up, the RPC will assist in contacting the client or in finding appropriate resources.

SMHW Providers Shall

• Implement some form of internal tracking and reminder system to ensure that SMHW clients who have abnormal breast test results suspicious for cancer receive further medical evaluation and treatment within 60 days. This assures scheduling follow-up visits and procedures are completed timely. In addition, client attendance for appropriate follow-up needs to be monitored. If there is a missed appointment, reschedule the appointment and assist with removing barriers such as transportation difficulties.
• Implement some form of internal tracking and reminder system to ensure that women who have abnormal cervical test results receive further medical evaluation and treatment within 60 days. This ensures that scheduling follow-up visits and procedures are completed timely. In addition, client attendance for appropriate follow-up needs to be monitored. If there is a missed appointment, reschedule the appointment and assist with removing barriers to care, such as transportation.
• Promptly notify the RPC when a client is referred to BCCT in order to ensure timely and complete follow-up, complete and accurate tracking and documentation as such. Please report additional information to the RPC who can enter the information onto forms as needed, such as treatment of cancers found.
• SMHW requires two documented attempts for client follow-up, if needed.
  • Direct telephone communication is the most effective contact method.
  • If unable to reach client by telephone, a letter should be sent indicating there is need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.
  • If no response after the second attempt or the client refuses further diagnostics and/or treatments, notify the RPC.
  • Utilize a tracking system to ensure that clients show up for scheduled visits and receive the appropriate diagnostic or treatment services.
  • If clients do not keep follow-up appointments, implement attempts to reach the client for rescheduling the appointment by telephone or by mail within 30 days.
  • If the client is no longer reachable or attempts to contact the client fail, please inform the RPC for the provider area within 30 days.

Abnormal Cervical Screening Results

A mandatory component as a provider of the SMHW program is the responsibility for providing clinical case management of abnormal findings, as well as reporting the abnormal findings and the outcomes to the SMHW program on a timely basis.

The clinician, using current standards of practice and the established SMHW cervical cancer screening protocols, determines abnormal findings clinical case management type and frequency.

Providers must ensure the following

Suspicious or Abnormal Cervical Results

Clients with suspicious or abnormal cervical results will receive the necessary case management as determined by the clinician based on current standards of practice for rescreening, diagnosis and/or appropriate treatment, and clinicians will report data to SMHW.

CDC - 60 days or less from a suspicious for cancer screening result to diagnosis.
Standard - 60 days or less from time of CIN 2 or CIN 3/CIS diagnosis to start of treatment.

Determination of Screening Results

Suspicious screening results will be determined as normal or abnormal through short-term rescreening or diagnostic procedures.

• Notify and explain to the client with abnormal findings the need for any additional diagnostic service(s).
• SMHW requires two documented attempts for client follow-up, if needed.

Direct telephone communication has been shown to be the most effective contact.

If unable to reach the client by telephone, a letter should be sent indicating there is a need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.

If no response is received after the second attempt or the client refuses further diagnostics and/or treatments, notify your RPC.

Pending Abnormal Screening Results

If abnormal screening results are pending for ten (10) months or longer, client eligibility must be checked and a new annual screening test must be performed before the initiation of further diagnostic studies. SMHW will only reimburse for additional diagnostic services if the client continues to meet SMHW eligibility guidelines.

• For clients referred to direct billing diagnostic providers (Section 9 – Billing Guidelines), continue to track that the client receives/attends the scheduled appointments.
• For a client diagnosed with cancer, SMHW providers must provide the following information to SMHW:
  Date treatment started
  Type of treatment initiated
  Name of the facility where the treatment occurred

Protocol for Rescreen

Follow these guidelines in the instances where performance of a rescreen is needed.

Pelvic Examination

• A repeat pelvic exam is optional as a rescreen in less than ten (10) months if the previous abnormal pelvic exam reported to SMHW was not within normal limits due to an abnormal cervical finding.

Pap Test

• Reimbursement occurs only when pap test is following the ASCCP guidelines.
• SMHW does reimburse for HPV DNA genotyping.
• HPV DNA genotyping is not considered the same as HPV testing.
• HPV DNA-specific genotyping 16/18 is an ASCCP option that recommends being done with normal pap/HPV positive results to determine if further diagnostic follow-up is needed.
• Or, the provider can choose not to do genotyping and co-test (pap/HPV) in one year.
• Both are acceptable ASCCP options.

• See link to ASCCP Guidelines on page 6.7.
• If rescreen results are suspicious for cancer, proceed with diagnostic procedures as indicated by ASCCP guidelines.

Specialist Consultation Guidelines

A SMHW client may be referred for a specialist consultation following abnormal screening and/or diagnostic test results. Refer clients requiring a specialist consultation to a surgeon, OB/GYN specializing in breast and/or cervical health, or a physician or nurse practitioner who works for a cancer diagnostic or treatment center.

Specialist Consultation Reminder

• Retain a copy of the consult in the client’s chart. Do not submit a copy to SMHW.

Not Considered a Specialist Consultation

• Referral to the same screening examiner is not a specialist consultation.
• Referral for the standard/routine follow-up, such as a colposcopy by a nurse practitioner for a LSIL, is not eligible for a specialist consultation. (The appropriate follow-up is known; therefore, referral for a specialist consultation to determine the management of the problem is not required).

Diagnostic Services Available

Pap Test Exceptions

• An allowable exception is to extend the diagnostic follow-up interval to 60 days for women with an abnormal pap test result of ASC-H or worse, including “Presumed abnormal.”
• An exception in counting the number of days has been made for women referred into the program for diagnostic evaluation after an abnormal pap test result is received from a non-SMHW provider. In this instance, the interval shall begin on the referral date for diagnostic testing rather than the date of the initial pap test.

Guidelines for Cervical Diagnostic Services

If the repeat pap test is more than ten (10) months from the previous pap test, then the pap test should be part of a complete annual screening.

High-Risk Human Papillomavirus (HPV) Testing

• For five (5) years, the SMHW program will not reimburse for additional HPV testing if the initial pap result is negative.
• If the HPV is positive, refer to the ASCCP guidelines.

Cervical Conization

• Conization by LEEP, or cold knife, is usually considered to be treatment and is covered by MO HealthNet BCCT. If colposcopy is inadequate, or the client is not eligible for BCCT, please call your RPC for additional instructions to meet the client’s needs.
• All LEEP and cold knife procedures qualify for presumptive eligibility for Presumptive Eligibility BCCT with a pap test result of HSIL, AGC or worse followed by a colposcopy or tissue pathology, even if the tissue pathology is benign/CIN I.

Yellow Cervical Form

All forms are specific for each grant year. When entering an electronic or a paper form, use the version of the form that is dated correctly and corresponds with the date of service. At the beginning of each grant year there are multiple versions of this form in MOHSAIC. Click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner.

• A blue screening form must accompany or precede the yellow cervical form. A SMHW or a non-SMHW provider must base the diagnostic service on an abnormal screening result.
• The CDC requires information from the yellow cervical form and is crucial for statistical reports and studies. Keep all information confidential.
• Enter the information on the original form into the MOHSAIC system. File all reported information in the client’s record.
• Access MOHSAIC electronic forms online.
• A copy of the yellow cervical form is located on pages 10.14-.15 or download a copy online.
• If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

ASCCP Algorithms are available online in PDF form in English and Spanish. Visit https://www.asccp.org/guidelines/screening-guidelines/. 

The 2019 ASCCP Risk-Based Management Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors are available online at http://www.asccp.org/guidelines. This is an additional reference tool when the ASCCP Algorithms direct you to “Manage per ASCCP Guidelines.”

Alert Value Follow-up

The MOHSAIC electronic reporting system produces lists of clients and the SMHW providers who reported abnormal, suspicious for cancer results. The RPCs receive these lists at least weekly. The RPCs check the MOHSAIC reporting system to determine if follow-up is timely. If no information is entered into MOHSAIC regarding the necessary follow-up, the RPC will contact the provider to ensure that follow-up has occurred and that it will be reported by the provider; or, if the provider or client is experiencing difficulty in completing the follow-up, the RPC will assist in contacting the client or in finding appropriate resources.

SMHW providers shall

• Implement some form of internal tracking and reminder system to ensure that SMHW clients who have abnormal breast test results suspicious for cancer receive further medical evaluation and treatment within 60 days. This ensures that scheduling follow-up visits and procedures are complete and timely. In addition, client attendance for appropriate follow-up needs to be monitored. If there is a missed appointment, reschedule the appointment and assist with removing barriers such as transportation difficulties.
• Implement some form of internal tracking and reminder system to ensure that women who have abnormal cervical test results receive further medical evaluation and treatment within 60 days. This ensures that scheduling follow-up visits and procedures are complete and timely. In addition, monitor client attendance for appropriate follow-up. If there is a missed appointment, reschedule the appointment and assist with removing barriers such as transportation.
• Promptly notify the RPC via e-mail, telephone, or fax when a client is referred to Presumptive or Full BCCT in order to ensure timely and complete follow-up, complete and accurate tracking and documentation as such. Please report additional information to the RPC who can enter the information as needed, such as treatment of cancers found.
• SMHW requires two documented attempts for client follow-up.

Direct telephone communication is the most effective contact method.

If unable to reach client by telephone, a letter must be sent indicating there is need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.

If no response after the second attempt or the client refuses further diagnostics and/or treatments, notify your RPC.

Utilize a tracking system to ensure that clients show up for scheduled visits and receive the appropriate diagnostic or treatment services.

If clients do not keep follow-up appointments, implement attempts to reach the client for rescheduling the appointment by telephone or by mail within 30 days.

If the client is no longer reachable or attempts to contact the client fail, please inform the RPC for that provider’s area within 30 days.

Cervical situations that require follow-up within 60 days include:

• “Diagnostic work-up planned” is marked on any of the reporting forms for abnormal cervical findings.
• “Referred for diagnostic testing” is marked on the blue screening form or the yellow cervical form for abnormal cervical findings.
• Yellow cervical forms that are marked with “abnormal suspicious for cancer results” or are marked as “positive for cervical cancer”, require the “Status of Final Diagnosis section B” to be completed.
  Any diagnostic result on the diagnostic form that has an “*” in Section B requires a Final Diagnosis be marked in Section C.
  Final Diagnostic Results in Section B or C that indicate malignancy need to have Section D Cervical Treatment completed with the status of treatment, type of treatment, treatment facility, and date treatment started inserted.

Beginning in October 2000, signed federal legislation allows funded programs in the NBCCEDP to participate in the MO HealthNet BCCT Act. In July 2001, Governor Bob Holden signed legislation authorizing matching funds for Missouri to participate in the Missouri Medicaid program, now known as the MO HealthNet program, effective August 28, 2001. (State Statute RSMo Section 208.151 [25] is available at https://revisor.mo.gov/main/OneSection.aspx?section=208.151&bid=47992&h….)

Most women who receive a SMHW paid screening and/or diagnostic service, and are found to need treatment for breast and/or cervical cancer or a precancerous condition, may be eligible for BCCT in Missouri.

Once a client is enrolled into BCCT, they are qualified for full MO HealthNet benefits, as well as medical services for cancer care. Please note there is also transportation assistance available for the client enrolled in BCCT. Eligibility criteria for MO HealthNet are based on need. Details for BCCT are at http://dss.mo.gov/mhd/general/pages/about.htm.

Basic BCCT Act Eligibility Guidelines

Those who are eligible for the BCCT program must be enrolled in the SMHW program prior to tissue biopsy and have screening or diagnostic tests paid by SMHW.

• A Missouri resident.
• A female.
• Under the age of 65.
• Social Security Number.
• Citizenship or Qualified Alien Status.
• Diagnosed with breast and/or cervical cancer or cervical precancerous condition through SMHW.
• Need treatment for breast and/or cervical cancers or precancerous conditions as listed below.

BCCT Temporary MO HealthNet Authorization Letter Presumptive Eligibility

The BCCT Temporary MO HealthNet Authorization letter (page 10.16 or download online), also referred to as Presumptive Eligibility (PE), provides temporary and immediate full MO HealthNet benefits. Clients must meet basic BCCT eligibility guidelines (above) to qualify for PE.

MO HealthNet determines the date PE begins. Typically, PE coverage begins on the date of the procedure or diagnostic test that indicates either a precancerous condition or cancer of the breast and/or cervix by tissue pathology that determined the client is eligible for BCCT (pages 7.2-.3).

In order for a SMHW client to obtain PE, e-mail the completed BCCT Temporary MO HealthNet Application (page 10.16) to the MO HealthNet Service Center, Greene County Family Support Division (FSD) (page 7.4). The client receives a copy of the BCCT Temporary MO HealthNet Authorization Letter. An additional copy is retained for the client’s record. Notify the RPC of eligible clients. This procedure allows for minimal delays for women in receiving the necessary treatment indicated.

Submit the previously noted documentation for MO HealthNet to determine the date PE begins. PE coverage continues until the earlier of the following dates:

• The last day of the month following the PE decision, if the client does not submit an application for regular BCCT MO HealthNet coverage (page 10.17), 

  OR

• The date the client is determined ineligible or eligible for BCCT MO HealthNet.

BCCT MO HealthNet Application (Extended BCCT Coverage)
Extending MO HealthNet Treatment Eligibility beyond the presumptive period

For evaluation of continued MO HealthNet coverage, submit the (extended) BCCT MO HealthNet Application form for medical assistance to the FSD’s MO HealthNet Service Center at the time of cancer diagnosis.

The client must meet the basic BCCT guidelines (page 7.2) and:

• Have a Social Security number
• Be uninsured or underinsured for breast or cervical cancer treatment
• Show proof of citizenship/alien status
• Submit a completed, signed (extended) BCCT MO HealthNet Application form to the MO HealthNet Service Center via Greene County FSD

It is important for providers to assist clients in completing and e-mailing the Missouri BCCT MO HealthNet Application for medical assistance as soon as possible (refer to page 10.17). SMHW providers e-mail a copy of the application/temporary documents to MRT.ProcessingCenter@dss.mo.gov. The forms will then be forwarded to the appropriate person. E-mailing the forms is preferable; if unable to utilize e-mail, please fax the form to 573-526-9400 and mail the paper copies to 101 Park Central Square, Springfield, MO 65806. Please see the address listed above. Application-related questions can be addressed by calling 888-275-5908.

Upon review of the application, and if the client is determined eligible for BCCT MO HealthNet coverage, full MO HealthNet benefits will continue until the treating physician determines treatment for the breast or cervical cancer is complete.

Copies of the BCCT forms are located in Section 10 or downloadable online:

Clients determined ineligible for BCCT medical assistance may receive, with prior authorization from SMHW, a cervical conization by LEEP or cold knife.

Instructions to Transfer a Client from Another State BCCT Program

• The client should complete the Full BCCT MO HealthNet Application Form (page 10.17)
• Complete the Certification of Need for Treatment Form (pages 10.18-10.19)
• Provide the clinic’s name and telephone number as contact information to MO HealthNet.
  Information is used to verify enrollment in the Breast and Cervical Program of that state.

• E-mail all documentation to MO HealthNet Service Center at MRT.ProcessingCenter@dss.mo.gov

  OR

• Fax, if necessary, to 573-526-9400, and mail all paper copies to:

  FSD Customer Relations Unit
  101 Park Central Square
  Springfield, MO 65806

MO HealthNet Treatment Services Covered

Covered Services

• Cervical conization
• LEEP or cold knife – if a client received a pap test diagnosis of HSIL or worse, or colposcopy test diagnosis of moderate dysplasia or worse
• Incisional and/or Excisional breast biopsy – if ultrasound result is category 4 (suspicious abnormality) or category 5 (highly suggestive of malignancy)
• Incisional and/or Excisional breast biopsy – if fine needle aspiration, core needle, or stereotactic biopsy result is malignant
• Breast Cancer Treatment is indicated including chemotherapy, surgery, radiation, and breast reconstruction
• All other MO HealthNet covered medical services, including services not related to the breast or cervical cancer

SMHW Provider Responsibilities

SMHW Providers will:

• Notify client of diagnosis and recommended follow-up (preferably in person). If a specialist is treating the client, ensure that the client received the diagnosis and recommended follow-up.
• Explain the BCCT program and application processes to the client.
• Determine the client’s presumptive eligibility; complete the BCCT Temporary MO HealthNet Authorization letter (page 10.16).
• E-mail the letter to the FSD’s MO HealthNet Service Center within five days of BCCT qualifying test results or diagnosis.
• When MO HealthNet coverage is needed beyond the temporary PE period, assist the client in completing and signing the (extended) Missouri BCCT MO HealthNet Application (page 10.17) or download online.
  Ensure:
  • The client receives a copy of the completed application form.
  • A copy of the completed form is retained in the client’s medical record.
  • Verify dates included on eligibility documents are correct before sending to MO HealthNet Service Center.
  • Submit the application to the MO HealthNet Service Center for application evaluation as soon as possible after cancer diagnosis.
  • FSD’s MO HealthNet Service Center shall evaluate the application of each client for other MO HealthNet programs the client may be eligible to receive.
• Notify the SMHW RPC of clients who become eligible for the BCCT MO HealthNet Treatment program. The RPC will track the treatment provider’s name, date that the client’s treatment regimen started and the type of treatment initiated.
• Ensure entry of the client’s history and abnormal screening forms into the MOHSAIC reporting system prior to submitting the BCCT application forms. Utilize the Department Client Number (DCN) assigned to the client when entering the SMHW green history form (page 10.8-.9) into MOHSAIC.
  • This number serves as the MO HealthNet client number for the temporary PE letter and the full BCCT application for benefits.
• Submit date treatment was initiated, type of treatment that was started, and name of treatment provider by completing Section D on the purple breast form, and/or Section D on the yellow cervical form.
• Check the “yes” box in Section A of the SMHW purple breast or yellow cervical form(s) when BCCT services initiated.

SMHW Regional Program Coordinator BCCT Responsibilities

Regional Program Coordinators will:

• Check with client to assess status of the client’s cancer treatment upon request from FSD’s MO HealthNet.
• Assure treatment initiated and documented in MOHSAIC.
• Inform FSD’s MO HealthNet of the following:
• Follow-up biopsy result that does not document cancer diagnosis. In these cases, typically the PE BCCT has been issued for results of ultrasound category 4, category 5, or for HGSIL Pap smear result and the biopsy obtained during the PE timeframe is benign. No treatment is needed, so the extended full BCCT application does not need to be approved.
• Continue to track client’s BCCT treatment status and plan of care for breast and/or cervical cancer. MO HealthNet eligibility ends when treatment for the breast and/or cervical cancer is completed. After the MO HealthNet eligibility end date is documented, SMHW annual services can be offered to the client if all areas of eligibility are met.
• Date client gains insurance coverage.
• Date client moves out of state.
• Date client is determined lost to follow-up after documented attempts by the provider and RPC to inform and assist client with barriers to care, or
• Date client refuses care (signed waiver form or certified letter returned).

Family Support Division Responsibilities

Family Support Division will:

• Enter BCCT Temporary MO HealthNet Authorization letter for presumptive eligibility in the FSD system upon receipt from SMHW provider.
• Enter Missouri BCCT MO HealthNet Application for medical assistance into the FSD system upon receipt from client or the SMHW provider.
• Determine MO HealthNet eligibility for breast and/or cervical cancer treatment and other MO HealthNet programs.
• Report eligibility determination result to the client and the appropriate SMHW provider or RPC.
• After establishment of MO HealthNet approvals for breast and/or cervical treatment, track client’s need for continued treatment and continued enrollment in MO HealthNet.
• Request the treating physician’s plan of care for breast and/or cervical cancer treatment.
• Utilize SMHW RPC for assistance, if needed.
• Terminate breast and/or cervical cancer treatment eligibility after treatment is completed.
• Notify client and SMHW provider or RPC of termination of breast and/or cervical cancer MO HealthNet treatment eligibility.
• Provide tracking for initial treatment type and date to the SMHW RPC.

The CDC evaluates the SMHW program’s ability to meet established core program performance indicators. Performance indicators are evaluated from the Minimum Data Elements (MDEs) submitted by DHSS every October and April. MDEs are standardized data elements that provide consistent information on patient demographics, screening results, education, diagnostic procedures, and treatment information. Collect MDEs on women screened and/or diagnosed with program funds. Obtain MDE data from the history, assessment, screening, and diagnostic reports entered into the MOHSAIC system.

SMHW Core Program Performance Indicators

Quality Assurance

The goal of the Quality Assurance (QA) program component is to ensure that appropriate services are provided to each client and that program funds are utilized as required by program protocols. QA activities ensure high-quality medical standards of care are provided to women receiving SMHW and WISEWOMAN screenings, diagnostic and education services, as well as referrals for treatment when appropriate.

DHSS monitors and evaluates the quality and appropriateness of client care using the following QA activities:

• Incorporating data edits in the MOHSAIC electronic reporting system that limit the reporting of inappropriate and inaccurate client service records.
• Reviewing electronically submitted client service reports for compliance to standards of care prior to approval for reimbursement.
• Tracking alert values (abnormal testing results) to ensure clients receive appropriate diagnostic services and access to treatment, if needed.
• Performing initial on-site QA monitoring at each new SMHW and WISEWOMAN provider six months after first client is served and every two years thereafter. Scheduled QA monitoring occurs at any time deemed necessary by DHSS staff because of questionable reports (page 8.5).
• Providing training and technical assistance to providers to improve quality of care based on results of QA monitoring.
• Evaluating client and provider expectations.

Quality Assurance Follow-up

At the time of the provider’s on-site review, technical assistance is provided by the RPC to clarify or demonstrate any points of confusion. After the on-site review, follow up with a post-review letter describing any areas needing improvement. Follow-up may be conducted to review success in instituting the recommended improvements. If the RPC determines a provider has consistently not met the program's clinical standards, the provider is asked to complete a corrective action plan. Typically, the RPC conducts another review in six (6) months to ensure implementation of the corrective plan and the provider is working to resolve the problem.

Quality Assurance Provider Expectations

QA monitoring will monitor providers’ compliance with the following expectations:

Client Rights

• Privacy
• Confidentiality
• Access to test results
• Follow-up of medical problems through referrals, diagnosis and treatment
• Client will not be held financially responsible if identified as a SMHW client
• Access to an interpreter
• Treatment per Civil Rights Act
• Treatment per Americans with Disabilities Act

Intake and Eligibility Guidelines

• Staff knowledge of SMHW/WISEWOMAN eligibility guidelines
• Procedure to screen and identify clients
• Annual review of clients for continued eligibility

Screening and Diagnostic Protocols

• Screening includes pelvic exam, pap test, CBE, and mammogram, if appropriate
• Standards and protocols for follow-up

• Procedure to track clients with abnormal results, including:

  • Name of client
  • Test
  • Date test completed or missed appointments rescheduled
  • Results and that client is notified of results
  • Referrals including tracking that appointments were kept or rescheduled
  • Follow-up visit dates, if needed
  • Documentation of complete Plan of Care/Treatment to include facility, treatment start dates and treatment type
  • Disposition of client status regarding follow-up, refusals of treatment or diagnostic testing recommended. Report to the RPC problems with missed appointments, lost to follow-up or refusals, promptly

   

Clinic Management

• Staff is trained and familiar with provider guidelines
• Policy and procedures are in place for billing and filing forms
• Procedure to track amount of program funds is in place
• Maintain professionally licensed or certified staff to perform program activities
• Notify SMHW Central Office including RPC of staffing changes promptly regarding the need for provider or rescinding clinic staff MOHSAIC access and to schedule SMHW training for new hires
• Track clients who receive screening and diagnostic results to provide complete case management from the initiation of care to the end of the plan of care
• If missed appointments or refusals of follow-up recommendations occur, make attempts to contact the client to reschedule and let the RPC know about situations regarding missed or refused follow-up
• The facility is clean with appropriate space for screening
• There is an in-house plan for quality checks at regular intervals
• Provide Navigation Services for women who have not been screened:
  • A minimum of two documented client visits, and
  • A completed navigation form in the record is required.

SMHW Quality Assurance Form

View form

Billing Guidelines June 30, 2024

The billing guidelines for the DHSS SMHW and providers outlined in this section are effective June 30, 2024.

Provider Reimbursement Guidelines

The guidelines for provider reimbursement are in accordance with the Breast and Cervical Cancer Mortality Prevention Act of 1990, Public Law 101-354. Congress amended the NBCCEDP Public Law 101-354 in 1993 to create the WISEWOMAN Program. The conditions and requirements are:

• DHSS/SMHW is the payor of last resort,
• DHSS reimbursements are considered payment in full,
• Service providers and their subcontractors shall not charge the client for any screening/diagnostic services reimbursable by DHSS,
• DHSS clients shall not be charged any administrative fees,
• When services other than the breast and cervical cancer screenings/diagnostics are performed, and/or the WISEWOMAN cardiovascular risk assessment, documentation shall be provided that verifies the client was notified in advance of these services and their cost, and
• DHSS will cover only outpatient services.

Reasons for Denial

Resubmission for denied service will only be considered one time. Submit questions pertaining to client’s data reporting form for service denied/adjusted to the DHSS by telephone toll-free at 866-726-9926 or fax to 573-522-3023. Denial will be explained or reconsidered.

No further resubmission will be accepted after the second denial.

Providers will not receive reimbursement under the following circumstances:

• Services are provided to ineligible women
• Standards outlined in the Provider Manual as stated in Sections 4, 5 and 6 are not met. Examples:
  • Rescreen CBE after diagnostic work-up will not be reimbursed unless the original screening CBE was abnormal.
  • Rescreen pap test does not follow ASCCP guidelines.
• Breast and/or cervical screening services are incomplete
• Mammography, ultrasound and/or pap test results are reported as unsatisfactory. In the case of unsatisfactory results, the test must be repeated and the results reported to SMHW
• Required client and completed reporting forms are not submitted to SMHW within 90 days of service, with the exception of filing with client's insurance, which must be submitted within 30 days from receipt of the Explanation of Benefits (EOB)
• If information is submitted after the closing date for grant year, it cannot be reimbursed by SMHW/WISEWOMAN or billed to client

Insurance Guidelines

• If the client has insurance, the provider shall first bill the client’s insurance company for services received.
• Women who meet the SMHW guidelines and have private insurance or enrolled in PPOs, but who are financially unable to pay the deductible or co-payment, are eligible for SMHW.
• The client’s insurance must be billed first; then include the insurance payment amount made to the facility for the covered procedures in the “Comments” section on reporting forms when billing DHSS. SMHW will only reimburse up to the total amount allowed for the procedure per program guidelines. The total amount allowed and reimbursed by SMHW for each CPT includes any payments received from insurance, not in addition to insurance payments.
• In MOHSAIC, under comments, please indicate what insurance provider paid for each procedure in detail by SMHW Approved CPT Code and descriptive line item. For example, $68.23 for pathology (CPT 88305), $120.97 for mammogram, (CPT 77067) and $468.54 for percutaneous breast biopsy with stereotactic guidance (CPT 19081). Show Me Healthy Women procedures will only reimburse at the contracted program amount which is based on current MEDICARE reimbursement rates (Missouri 01).
• Provider must retain a copy of documentation of the EOB, deductibles or co-payment requirements in the client’s chart along with a copy of the client’s insurance card. It is the responsibility of the provider to keep a copy of the insurance EOB in the clients’ files for quality monitoring.
• The payment received by Show Me Healthy Women is based on Show Me Healthy Women contract rates, not the rate of a commercial insurance company, or public. Show Me Healthy Women payment is NOT based on the clients’ out-of-pocket responsibility as stated in the insurance EOB. SMHW payment is determined based on the amount the insurance carrier pays the provider for each procedure/CPT code.
• SMHW Providers and their subcontractors cannot bill a SMHW client for any SMHW/WW services.
• Women enrolled in prepaid/managed care and health plans (such as HMOs, POS and MO HealthNet Managed Care [formerly MC+]) are not eligible for SMHW services.
• For additional information about clients with insurance, refer to page 3.2.

Administrative Referral Fee

An administrative referral fee is billable for the following:

• When a SMHW client receives a screening from a clinician that is not a SMHW provider, the SMHW provider must submit to the program the patient history and screening forms containing the screening results from the non-SMHW provider as “Reporting Only”
• Administrative referral fee will be paid one time per client, per provider, during an annual screening cycle
• Direct billing providers may bill an administrative referral fee if the client was referred from another provider for a screening mammogram or diagnostic services
• Bill the administrative referral fee on the blue screening form (pages 10.10 - 10.11) or diagnostic forms (pages 10.12-13)

Direct Billing Diagnostic Providers

SMHW has agreements with the following medical entities, referred to as direct billing diagnostic providers, to provide diagnostic services:

• Barnes Jewish Hospital, St. Louis—St. Louis City
• Barnes Jewish Hospital, St. Peters—St. Charles County
• Bothwell Regional Health Center—Pettis County
• Breast Healthcare Center (Missouri Baptist Hospital), St. Louis—St. Louis County
• Golden Valley Memorial Hospital, Clinton—Henry County
• Missouri Delta Medical Center, Sikeston—Scott County
• SSM DePaul Hospital, Bridgeton—St. Louis County
• SSM Health St. Clare Hospital, Fenton—St. Louis County
• SSM St. Joseph Health Center (breast only), St. Charles—St. Charles County
• SSM St. Mary’s Health Center, Richmond Heights—St. Louis County
• Mercy Hospital, St. Louis (David C. Pratt Cancer Center) (breast only)—St. Louis County
• Saint Louis University Cancer Center, St. Louis—St. Louis City
• Ste. Genevieve County Memorial Hospital, Ste. Genevieve—Ste. Genevieve County
• University Health Truman Medical Center—Hospital Hill, Kansas City—Jackson County
• University Health Lakewood Medical Center—Lakewood, Kansas City—Jackson County
• University of Missouri Hospital and Clinics—Ellis Fischel Cancer Center, Columbia—Boone County

Mammography Van Billing Guidelines

Mammography van screen should coordinate with a clinical breast exam performed by a SMHW provider in order to meet quality care guidelines and program requirements. When billing for a mammogram only performed on a mammogram van, select the visit type as “Mammogram Only”, mark the “Mammogram Van” box and complete “Section B5 Mammography provider facility” field. Include the name of the facility providing the van and include the word “Van” by the facility name. Example: Ellis Fischel Van.

Note: SMHW program reimburses the office visit of the provider performing the CBE for clients who have or had a mammogram on a mammography van. Each SMHW client should be referred to a primary care physician (PCP) for a CBE. (See Direct Billing Diagnostic Provider Responsibilities on page 9.6).

Screening/Referring Provider Responsibilities

The screening/referring provider shall:

• Verify the client’s eligibility for SMHW services according to the SMHW guidelines to include a signed and dated eligibility form (page 10.6).
• Assure that new SMHW clients complete a green history form (pages 10.8 [English] -10.9 [Spanish]).
• Complete/enter the blue screening form (pages 10.10-.11) with the screening results.
• Mammography Van, if a client presents at the mammography van and has not had a clinical breast exam (CBE) continue with screening services but refer them for primary care services so a CBE can be obtained. Document in Section D of the screening form.
• Call and make the appointment for the client with the direct billing diagnostic provider. Transmit copies of the enrollment history, eligibility form, and screening forms to the direct billers.
• Submit the green history and blue screening form information to SMHW as soon as possible with the appropriate billing or reporting-only information. If not, delayed payment for both screening and diagnostic services may occur.
• Share copies of the client’s notations and procedures with the referring practitioner.

Direct Billing Diagnostic Provider Responsibilities

The direct billing/diagnostic provider shall:

• Retain copies of the screening provider’s information in their files. The copies should include the screening results, client eligibility form, and history form.
• Provide the necessary diagnostic services.
• Complete a purple breast form (pages 10.12-.13), or a yellow cervical form (pages 10.14-.15), or a blue screening form (pages 10.10-.11), if a screening mammogram was performed. Submit data to SMHW.
• Send copies of the medical and pathology reports back to the referring screening provider. To ensure appropriate follow up, document the client has been notified of their results and maintain this information in the client’s medical record.

The direct billing and screening provider shall coordinate case management services of SMHW clients. Interruption of timely diagnostic services occurs with missed appointments. Reschedule missed appointments promptly.

Breast & Cervical Reimbursement Rates by CPT Codes

View reimbursement rates

The following pages contain sample forms associated with the SMHW and WISEWOMAN programs.

All current forms are available on the web.

Direct any form related questions to the agency’s RPC.

Client/Patient Navigation

View form

SMHW/WISEWOMAN Information Update

View form

SMHW Eligibility Agreement (English & Spanish)

View form

Green Patient History (English & Spanish)

View form

Blue Screening Report

View form

Purple Breast Diagnosis and Treatment

View form

Yellow Cervical Diagnosis and Treatment

View form

BCCT Temporary MO HealthNet Authorization

View form

BCCT Medical Assistance Application (MO HealthNet)

View form

Certification of Need for Treatment - Breast/Cervical Cancer

View form

Request for Literature

View form

Overview of Client Forms for MOHSAIC Entry

Providers entering on-line information are not required to fill out paper forms but must have documentation of the information submitted to the Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC) in the client files for quality assurance (QA) review.

Access the Patient History, Screening Report, Breast Diagnosis and Treatment, Cervical Diagnosis and Treatment, and Client Navigation forms online. Alternatively, call 866-726-9926.

All forms contain a ‘Comment’ section at the bottom of the form. This is used for additional notes on the client or procedures entered by the provider or DHSS staff. Explanations should be kept brief as space is limited. Comments are not mandatory, but helpful to retain information not covered in the form. Providers must submit completed client forms within 60 days of service.

If waiting for insurance reimbursement/approval forms, do not submit complete billing until the amount insurance paid is available. See page 9.3 for Insurance Guidelines.

Green Patient History Form

The Patient History form (green form, pages 10.8-.9) shall be completed by each client at the initial screening visit and at every annual screening thereafter. The provider shall enter the green history form into MOHSAIC when reporting the initial screening visit and update the information each year, as needed. Enter the green history form into MOHSAIC before entering any other form.

Blue Screening Report

A completed Screening Report form (blue form, pages 10.10-.11) shall be submitted at the initial, rescreen, and annual screening for all clients participating in SMHW. Document the first mammogram a client receives on the screening report.

Purple Breast Diagnosis and Treatment Form

The Breast Diagnosis and Treatment form (purple form, pages 10.12-.13) shall be fully completed for all clients with abnormal breast cancer screening results that require further diagnostic procedures and/or treatment. If needed, diagnostic service(s), date of service(s), results of diagnostic service(s), final diagnosis, and treatment (date, type and place) are also required on the purple form. This information is crucial for the successful follow-up and/or treatment of all clients with abnormal screening results.

Yellow Cervical Diagnosis and Treatment Form

The cervical Diagnosis and Treatment form (yellow form, pages 10.14-.15) shall be fully completed for all clients with abnormal cervical cancer screening results that require further diagnostic procedures and/or treatment. If needed, diagnostic service(s), date of service(s), results of diagnostic service(s), final diagnosis, and treatment (date, type, and place) are also required on the yellow form. This information is crucial for the successful follow-up and/or treatment of all clients with abnormal screening results.

MOHSAIC Access

MOHSAIC is an online data system used to collect and manage client service records for the SMHW and WISEWOMAN programs.

MOHSAIC also tracks funding allocations and expenditures and is linked to the Statewide Advantage for Missouri (SAM II) accounting system for reimbursing providers. Prior to reimbursement, SMHW and WISEWOMAN staff review all submitted forms to ensure client services meet program standards.

SMHW must submit Minimum Data Elements (MDE) reports to the Centers for Disease Control and Prevention (CDC) from the MOHSAIC reporting data forms.

How to apply for access to MOHSAIC

To apply for access to MOHSAIC, applicants will need to follow the instructions on the following pages.

MOHSAIC Access Instructions

Navigating MOHSAIC

Lesson 1: The CLIENT

This is for the Provider or MOHSAIC Customer. In this lesson, learn how to:

• Develop a new password
• Log onto the SMHW application
• Search for existing clients
• View Medicaid information
• Register new clients

Steps to Access the MOHSAIC Application and Log onto the SMHW Application

Log-in Process

Open the Internet browser and enter the Web address on the address line: https://healthapps.dhss.mo.gov/smhw/.

• If this is the first time to login, a password must be established:
  • Use the username and assigned password provided to you by e-mail from SMHW, when approved. User name is usually the first five letters of last name and first name initial. Initial password is first and last name initials and last four digits of SSN.
  • Click on ‘Change Password.’

  • If you do not login to MOHSAIC for 30 days, the system will ‘lock out.’ You must call the ITSD

    Help Desk at 800-347-0887 to unlock and enter new password.

  • After a password is established, the program will ask to change your password every 30 to 60 days. This can be numbers, letters, or a combination, as desired. Password requires six (6) to eight (8) characters and one numeric value.
• Once logged in, your agency name will appear and stay constant throughout the application.
• Click the ‘Login’ button to proceed.

Application Instructions

Patient Navigation

The CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP), defines Patient Navigation as individualized assistance provided to women to overcome barriers and facilitate timely access to quality screening and diagnostic services, as well as initiation of timely treatment for those diagnosed with cancer.

Navigation focuses on clients who otherwise would not complete recommended screening or diagnostic testing because of personal barriers, limited access to health services and other significant barriers to completing screening and diagnostic services. For clinic guidance on navigation services see Patient Navigation Services Guidance later in this section.

All women enrolled in the SMHW program must be assessed for their need for patient navigation services and provided with such services accordingly. SMHW providers complete the MOHSAIC Patient Navigation form for women enrolled in the SMHW program to reflect the assessment of barriers and actions taken for barrier reduction to achieve completed screenings.

Patient navigation must meet the CDC’s following six (6) requirements:

1. Written assessment of individual patient barriers to cancer screening diagnostics/initiation of treatment
2. Provision of education and support for the patient
3. Resolution of barriers to obtaining cancer screening/diagnostics/initiation of treatment
4. Tracking of the patient to assure completed screening/diagnostics/initiation of treatment
5. A minimum of two (2), preferably more, patient contacts
6. Data collection and data review in aggregate to evaluate outcomes of patient navigation (the delivery of cancer screening and/or diagnostic testing, final diagnosis and treatment initiation if needed).

CDC considers case management for women with abnormal screening results a type of patient navigation, as long as the aforementioned activities are performed.

Patient Navigation services are not limited to enrolled SMHW clients. Women who meet age and income requirements who have insurance to pay for screening and diagnostic services but need assistance with resolving barriers to completing screening or diagnostic services can be enrolled.

Navigation Service Eligibility

Patients with Navigation Service Eligibility

This additional enrollment status within SMHW is called ‘Navigation-Only’.

‘Navigation-Only’ Enrollment Status

SMHW’s enrollment status for Non-SMHW eligible women in MOHSAIC is called ‘Navigation-Only’. The enrollment status of ‘Navigation-Only’ allows payment to SMHW providers for navigation services provided to a woman who meets age and income requirements and has group or private insurance to pay for the screening and diagnostic services. ‘Navigation-Only’ enrollment is prioritized for populations that are predominantly low-income (<250% FPL) and are of appropriate age per screening guidelines. Women receiving ‘Navigation-Only’ services will be included in CDC’s reporting of women served through NBCCEDP.

Payer Sources Eligible for ‘Navigation Only’ Services

MDE data are required for women who receive NBCCEDP-funded ‘Navigation-Only’. The abbreviated record will include data on patient demographics, screening test type, date of test, test results, and final diagnosis.

The ‘Navigation-Only’ client abbreviated record includes the SMHW Patient History form (green) and the Patient Navigation Form (gray) and a Screening Report Form or Diagnostic form as applicable. Select Visit Type ‘Navigation-Only’ and ‘Reporting Only’ on the screening or diagnostic forms as applicable.

SMHW providers complete the Patient ‘Navigation-Only’ form for women in order to reflect the assessment of barriers and actions taken for barrier reduction to achieve completed screenings.

To qualify for enrollment into ‘Navigation-Only’ with an SMHW abbreviated record, the following six (6) requirements must be met.

1. Assessment of individual patient barriers to cancer screening/diagnostics/initiation of treatment
2. Provision of education and support for the patient
3. Resolution of barriers to obtaining cancer screening/diagnostics/initiation of treatment
4. Tracking of the patient to ensure completed screening/diagnostics/initiation of treatment
5. A minimum of two (2), preferably more, patient contacts
6. Data collection and data review in aggregate to evaluate outcomes of patient navigation (the delivery of cancer screening and/or diagnostic testing, final diagnosis and treatment initiation if needed).

Access to clinical information is necessary to complete the MDE record. MDE data for ‘Navigated-Only’ clients are analyzed separately and included in calculating the NBCCEDP core indicators.

A process for report/result sharing between health care agencies is required, as is informing each patient of their test result. Reporting the results of the screening or diagnostic services on the appropriate forms counts the woman as ‘Served’ by the program. To complete billing for Patient Navigation Services, reporting results of the screening and/or diagnostic test is required in MOHSAIC. The table below outlines the required forms by Navigation Service Type.

Patient Navigation Services

Navigation Service Type

MOHSAIC Navigation Form

The MOHSAIC Navigation form is located in Section 10: Forms. The Navigation Form includes the following sections:

• Personal Data and Client Assessment
• Barrier Identification (e.g. financial, communication)
• Action Plan
• Outcomes

Resources that may assist navigating clients through obtaining healthcare coverage include the Missouri Department of Social Services’ Medicaid Program.

Terminating Patient Navigation

Depending on screening and diagnostic outcomes, patient navigation services terminate when a client:

1. Completes screening and has a normal result,
2. Completes diagnostic testing and has normal results,
3. Initiates cancer treatment, or
4. Refuses treatment.

Case Management

Clients who have abnormal screening results receive follow-up services, up to the point of a final diagnosis and treatment start date. Achieve this through case management. The goal of case management is to ensure clients enrolled in the program receive timely and appropriate diagnostic and treatment services. An abnormal screening result is determined based on nationally recognized screening guidelines identified in the Provider Manual Chapters 5 and 6.

Non-clinical professionals may provide required case management activities, and a qualified health care professional (Registered Nurse, Nurse Practitioner, Physician Assistant or Physician in good standing to provide health care in Missouri) must have oversight. Although case management services vary based on an individual client’s needs, at a minimum, case management must include the following activities:

• Notify the client of an abnormal result within a reasonable period of time (i.e., two (2) weeks from the date the procedure was performed),
• Assessment and resolution of barriers to diagnostics services,
• Assessment and resolution of barriers to initiation of cancer treatment, if treatment is indicated,
• Client education and support,
• Arrange diagnostic appointments on the client’s behalf,
• Clients may not be given a referral list and asked to schedule their appointment,
• Client tracking and follow-up to monitor client progress in completing diagnostics and initiating treatment, and
• A minimum of two contacts with the client over the course of the screening and diagnostic cycle.

Terminating Case Management

When a client concludes cancer treatment, the treating physician releases the client to return to a schedule of routine screening, and the client continues to meet SMHW eligibility requirements, the client may return to the program and receive all services, including patient navigation or case management.

Clients screened through SMHW clinical services who are subsequently insured may continue to receive patient navigation services. In such instances, agencies are encouraged to continue navigating clients to ensure diagnostic procedures are completed, and if a diagnosis of cancer, that treatment is initiated.

Lost to Follow-up Cases

Funding received from the CDC is contingent upon SMHW meeting or exceeding several quality assurance parameters of the CDC Core Performance Indicators. Case managers must ensure and meet the following indicators for all SMHW clients with abnormal screening results:

• Ninety (90) percent or more of SMHW clients with abnormal findings achieve a definitive diagnosis.
• Seventy-five (75) percent or more of SMHW clients with an abnormal finding achieve a definitive diagnosis within 60 days or less.

A SMHW client contact and tracking system must be in place to notify clients of abnormal results. Contacts with a client should be clearly documented in a client’s medical record and should include what type of follow-up is needed, the recommended timeframe for follow-up, and the clinical implications if the follow-up does not occur. Client contact continues until one of the following occurs and is documented in the medical record:

• Recommended follow-up evaluation complete and the client referred for treatment (if indicated),
• Made two documented attempts to contact the client. If the client has a valid address, one of these attempts must either be in writing and sent as a certified letter or sent via the client portal/email with a read receipt confirmation. Use of certified letters or read receipt emails early in the course of follow-up can expedite the notification process,
• Notified the Regional Program Coordinator after no response,
• Documented informed refusal in the client’s medical record, or

• Documented in the client’s medical record at least two contact attempts made (considered lost to follow-up).

  a. This documentation should include the dates, types of contact attempted, and the outcomes.

  b. If the client has a valid address, at least one of the contact attempts should be a certified letter with a return receipt. Keep a copy of the certified letter and the return receipt in the client’s medical record.

Every client has the right to elect or refuse treatment. A client is considered to have refused service when one of the following has been carefully documented in the client’s medical record:

• Client has verbally refused the follow-up care recommended.
• Client has refused in writing the follow-up care recommended.

Keep documentation of the informed refusal in the client’s medical record. Include refused service or treatment and when the client was informed of the risks involved if recommended follow-up is not completed.

Quality Assurance/Quality Improvement

Documentation of Patient Navigation Services will be reviewed during the regular monitoring visits every two years and as necessary. Verification of eligibility for navigation services will be assessed. Notation of the assessment and appropriate interventions to assist with barrier reduction will be reviewed. Please refer to Section 8, Quality Assurance, for more information.

Patient Navigation Services Guidance

Patient navigation assists a patient so they can move through health care promptly without the road stops of a complex healthcare environment. This includes moving the patient through distinct healthcare settings such as primary care (clinic) and tertiary care (hospital). The goal is to eliminate barriers to timely health care through a one-to-one relationship between a navigator and the patient. No matter what phase of health care, the patient should benefit from an appropriately trained navigator at the phase of health care.

A patient navigator works with patients to reduce real and perceived barriers to health care. The services provided depend on barriers identified and actions taken to alleviate the barriers. Common barriers include:

• the inability to schedule and keep appointments,
• English as a second language,
• confusing medical information,
• lack of insurance,
• limited finances, and
• lack of or limited transportation to and from home.

Other barriers may emerge and must be recognized and addressed as the navigation plan develops.

Navigation is an early phase of health care and includes education about cancer prevention, cancer risk factors and the need for screening for those patients not engaged with obtaining health care or not a part of a health care system. It may also include educating patients already within a healthcare organization who have not received screening services. For patients already engaged with a healthcare organization, navigation may include education regarding timely follow-up appointments for further studies or beginning treatment.

Healthcare organizations must assess their capacity to support increased patient activity and anticipate an increase in screening rates.

Healthcare organizations with patient navigation involving medical record review and required documentation know exactly who is due for breast or cervical cancer screening and subsequently, contact those patients to encourage them to come in for the screening.

In managing navigation services, the organization asks the following in their capacity assessment:

• What setting -- primary care clinic, community-based affiliate, or regional-based tertiary care?
• Who is the target audience and priority population?
• How to provide services – in person, by phone, or both?
• Who will serve as navigator—lay person, nurse, or other?
• Who will all the partners be and how will they work together?

These organizations dedicate staff time to the appropriate phase of healthcare navigation for their patients.

Effectiveness evaluation components are “no-show” rates, completion of screening exams, and timely follow-up.

A successful navigation program will see a reduction in “no-show” rates, an increase in the completion of screening exams, and consistent timely follow-up of abnormal test results.

Navigation Services Tasks

Assigning responsibility for specific tasks increases an organization’s accountability for patient navigation. Consider these tasks for patient navigation:

The elimination of cancer disparities is critically important for lessening the burden of cancer. Patient navigator programs improve clinical outcomes.

In response to Missouri women and providers reaching out to SMHW to inquire about additional cancer navigational resources, SMHW developed a list of Cancer Navigational Resources to assist in filling a gap in the current healthcare system. The following pages contain the SMHW Cancer Resources to help navigate Missouri women and families to help at many points along the health care journey: insurance problems, identification of available cancer screening programs, medication assistance, financial assistance, housing assistance during travels, etc.

Show Me Healthy Women Cancer Resources

View resources

Providers

Client Referral

A complete list of providers is on the DHSS website. The list is updated regularly. Refer clients with Internet access to the website or they may call the SMHW toll-free number 866-726-9926.

RPC Contact Information

SMHW Regional Program Coordinator County List

View coordinator list

Request for Literature

Request literature using the “ Request For Literature” form available on Free Resources.

 

Available Literature in English

View literature

 

Available Literature in Spanish

View literature

Acronyms/Abbreviations

5 A’s – assess, advise, agree, assist, and arrange

A1C test – glycosylated hemoglobin test

ACS – American Cancer Society

ADA – American Diabetes Association

AGC – atypical glandular cells

AGUS – atypical glandular cells of undetermined significance

AHA – American Heart Association

AIS – adenocarcinoma in situ

ASCCP – American Society for Colposcopy and Cervical Pathology

ASC-H – atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

ASCUS – atypical squamous cells of undetermined significance

BCCCP – Breast and Cervical Cancer Control Project is the former name of SMHW

BCCT – Breast and Cervical Cancer Treatment (through MO HealthNet)

BMI – body mass index

BSE – breast self-examination

CBE – clinical breast examination

CDC – Centers for Disease Control and Prevention

CHD – coronary heart disease

CIN – cervical intraepithelial neoplasia

CIS – Cancer Information Service; carcinoma in situ

CLIA – Clinical Laboratory Improvement Amendments of 1988

CPT – current procedural technology (code)

CVD – cardiovascular disease

CVH – cardiovascular health

DBP – diastolic blood pressure

DCN – departmental client number

DHSS – Missouri Department of Health and Senior Services

DNA – deoxyribonucleic acid

DOB – date of birth

DSS – Missouri Department of Social Services

ECC – endocervical curettage

EOB – explanation of benefits

EFT – electronic funds transfer

FDA – Food and Drug Administration

FLP – fasting lipid panel

FNA – fine needle aspiration

FPL – federal poverty level

FSD – Family Support Division

HBP – high blood pressure

HDL – high density lipoproteins

HDL-C – high-density lipoprotein cholesterol

HIPAA – Health Insurance Portability and Accountability Act

HPV – human papillomavirus

HSIL – high-grade squamous intraepithelial lesion

HTN – hypertension

IFG – impaired fasting glucose

ITSD – Information Technology Services Division

JNC 7 – Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7, 2004)

Kg – kilograms

LDL-C – low-density lipoprotein cholesterol

LEEP – loop electrosurgical excision procedure

LSP – lifestyle program

LSIL – low-grade squamous intraepithelial lesion

MDEs – minimum data elements

MI – motivational interviewing

MOAP – Missouri Arthritis & Osteoporosis Program

MOHSAIC – Missouri Health Strategic Architectures and Information Cooperative

MQSA – Mammography Quality Standards Act of 1992

NBCCEDP – National Breast and Cervical Cancer Early Detection Program

NCCDPHP – National Center for Chronic Disease Prevention and Health Promotion

NCEP – National Cholesterol Education Program

NCI – National Cancer Institute

NHLBI – National Heart, Lung, and Blood Institute

NIH – National Institutes of Health

NMR – nuclear magnetic resonance

OATS – Older Adults Transportation Service

Pap Stain – Papanicolaou stain

Pap Test – Papanicolaou smear

PHNPAT – Public Health Nurses Physical Assessment Training

RN – Registered Nurse

RPC – Regional Program Coordinator

SBP – systolic blood pressure

SMHW – Show Me Healthy Women – The current name of Missouri Breast and Cervical Cancer Control Project (BCCCP).

SMTS – Southeast Missouri Transportation Service SSN – social security number

TC – total cholesterol

TLC – therapeutic lifestyle changes

WIC – Woman, Infants and Children Program

WISEWOMAN – Well-Integrated Screening and Evaluation for Women Across the Nation - A heart health risk assessment and education program for women receiving a Show Me Healthy Women cervical and breast cancer screening service.

WNL – within normal limits