Provider Manual - Show Me Healthy Women (SMHW)

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