Provider Manual - Show Me Healthy Women (SMHW)

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.