Provider Manual - Show Me Healthy Women (SMHW)

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.