Women's Health Connection Policy and Procedure Manual

Women’s Health

Connection Policy and

Procedure Manual

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FY 201720

18

DIVISION OF PUBLIC AND BEHAVIORAL HEALTH WOMEN’S HEALTH CONNECTION IN PARTNERSHIP WITH ACCESS TO HEALTHCARE NETWORK

FUNDED THROUGH THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)

GRANT # 1U58DP003929 | FY 2017FY 2019

FY 2019


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Table of Contents

Introduction .........................................................................................................2

Program Overview ................................................................................................2

Case Management Services ............................................................................... 324

3

Program Responsibilities .................................................................................... 45

Eligibility ..............................................................................................................5

Underinsured Policy ........................................................................................... 57

Women’s Health Connection Member ID Card ..................................................... 12

Women’s Health Connection Member ID CardUnderinsured Policy .................... 613

Reimbursable Screening Services ...................................................................... 714

Reimbursable Diagnostic Services ..................................................................... 917

Case Management Services ................................................................................. 24

Medicaid Assistance for Treatment of Breast and Cervical Cancer .................... 1425

Reimbursement and Billing ............................................................................. 1526

WHC Directory................................................................................................ 1729

Provider Resources ......................................................................................... 1831

Attachments .................................................................................................. 1932

- WHCPresumptive Eligibility Enrollment Form (English/Spanish)

o WHC- 40 to 64 years o Cervica l Ex pans ion 21-39

years )

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- Annual Screening Visit Form

- Mammography and Ultrasound Referral Form

- Breast Specialist Referral Form

- Cervical Specialist Referral

Surgery/Procedure Request From-

Breast Algorithm - PelvicCervical Algorithm

- ClientPatient Refusal Form ( E n g l i s h /S pa n is h )

Nevada Toabacco Quitline - Reimbursement Schedule

- Return Claims Denial Code

Introduction

Dear Provider,

Welcome to the Nevada Women’s Health Connection (WHC). This Policy and Procedure Manual provides information to contracted

health care providers with the Women’s Health Connection. It contains policy and procedures

of the WHC and serves as an operational reference for provider’s participating in the

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WHC. This manual is divided into sections for easy reference and to address the scope of the program. Providers are expected to conform to

the policy and procedures in this manual and all other revisions.

We appreciate your participation in the WHC and are looking forward to collaborate with

you in administering this program that provides preventative breast and cervical

screening services to Nevada women.

Sincerely, The Women’s Health Connection Team

Access to Healthcare Network

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Program Overview

About Women’s Health Connection

In 1990, Congress passed The Breast and Cervical Cancer Mortality Prevention Act due to an increase in the number of low-income and uninsured women being diagnosed with breast cancer. This bill authorized the Centers for Disease Control and Prevention (CDC) to establish the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide high-quality and timely breast and cervical cancer screening and diagnostic services to low-income, and uninsured women. The bill created the first national cancer screening program in the United States. NBCCEDP funds 67 programs including all 50 states, the District of Columbia, five US territories, and eleven tribes or tribal organizations.

In 1997, The Nevada Division of Public and Behavioral Health formerly known as the Nevada State Health Division, received funding from NBCCEDP to establish the Women’s Health Connection (WHC) Program. Since its implementation, WHC has been federally funded through NBCCEDP and has provided breast and cervical cancer screening services to over 57,536 women. WHC’s objective is to reduce breast and cervical cancer morbidity and mortality rates to medically underserved women in Nevada. This is accomplished through education, screening, and early diagnosis. As a result of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354), women who are enrolled and active in Women’s Health Connection program for breast and cervical cancer screenings and diagnosed with breast or cervical cancer have access to treatment services through Medicaid and or expanded Medicaid.

The Division of Public and Behavioral Health entered into a multi-year contract in 2011 with Access to Healthcare Network (AHN) to administer the Women’s Health Connection program. This partnership increases the access to primary and specialty healthcare services for breast and cervical cancer screenings for Nevada women.

The priority population for WHC are women between the ages of 21 to 64 years old. The priority populations for cervical cancer screening are women 21 to 64 years of age and 40 to 64 years of age for breast cancer screenings.

“The mission of Chronic Disease Prevention and Health Promotion is to maximize the health of Nevadans by improving policy, systems and environment that influence quality of life”

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Case Management

Case Management Services To improve access to screening, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990, and the Centers for Disease Control and Prevention (CDC) created the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP funds all 50 states, the District of Columbia, 5 U.S. territories, and 11 American Indian/Alaska Native tribes or tribal organizations to provide screening services for breast and cervical cancer. The program helps low-income, uninsured, and underinsured women gain access to breast and cervical cancer screening and diagnostic services. The Division of Public and Behavioral Health receives funding from NBCCEDP to conduct the Women’s Health Connection (WHC) Program through a competitive grant process. Since its inception in 1997, WHC has been 100% federally funded through NBCCEDP and has provided breast and cervical cancer screening services to over 50,373 women in Nevada. The goal of this program is to reduce breast and cervical cancer morbidity and mortality rates of medically underserved women in Nevada. This is accomplished through education, screening, diagnosis, and treatment. As a result of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354), eligible women screened and diagnosed with breast or cervical cancer, or found to have high grade cervical pre-cancer diagnosed through the Women’s Health Connection Program have access to treatment services through Medicaid if eligible. The Division of Public and Behavioral Health entered into a multi-year contract in 2011 with Access to Healthcare Network (AHN) to administer the Women’s Health Connection program. This partnership increases the access to primary and specialty healthcare services for breast and cervical cancer screening to Nevada women. The priority populations for WHC cervical screenings are 21 to 64 years old women, and for WHC breast screenings the priority populations are 40 to 64 years old women. Below is a summary of the screening services that are available to Nevada eligible women:

Cervical services age 21-29 years old: Annual pelvic exam Pap test Referral for treatment Diagnostic services after an abnormal screening result Referral for treatment

Cervical services age 30-64 years old: Pap test or co-testing (Pap and HPV test) as recommended by the examining clinician o Annual pelvic exam Pap test or co-testing (Pap and HPV test) as recommended by the examining clinicianReferral

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for treatment Diagnostic services after an abnormal screening result Referral for treatment

Age 40 years and older: Annual pelvic exam Pap test or co-testing (Pap and HPV test) as recommended by the examining clinician Annual clinical breast exam Diagnostic services after an abnormal screening result Referral for treatment Age 50 and older:All services above plus an annual screening mammogram

All services above plus an annual screening mammogram The Division of Public and Behavioral Health entered into a multi-year contract in 2011 with Access to Healthcare Network (AHN) to administer the Women’s Health Connection program. This partnership increases the access to primary and specialty healthcare services for breast and cervical cancer screening to Nevada women. Care coordination/case management services ensure that WHC clients receive timely and appropriate screening and diagnostic testing and if necessary, treatment services. Care coordination also supports clients in overcoming barriers that may prevent them from receiving follow-up and regular screening services. CCare coordination/case management services involvesare a collaboratingve process with providers to meet the health needs of women. all providers to meet the women’s health needs. The NBCCEDP evaluates WHC’s performance through Minimum Data Elements (MDEs), which are quality assurance measures. MDE’s contain screening and diagnostic data which is submitted bi-annually in April and October. NBCCEDP has set core performance indicators with benchmarks to ensure timely, complete, and accurate data is collected.

Core Program Performance Indicators Indicator

Type DQIG Item

Program Performance Indicator CDC

Standard

Screening 6a. Initial Program Pap Tests; Rarely or Never Screened > 20%

19e. Mammograms Provided to Women > 50 Years of Age > 75%

Cervical Cancer

Diagnostic Indicators

11a. Abnormal Screening Results with Complete Follow-Up > 90%

16.d. Abnormal Screening Results; Time from Screening to Diagnosis > 90 Days

< 25%

17 Treatment Started for Diagnosis of HSIL, CIN2, CIN3, CIS, Invasive

> 90%

18.d. HSIL, CIN2, CIN3, CIS; Time from Diagnosis to Treatment > 90 Days

< 20%

18.g. Invasive Carcinoma; Time from Diagnosis to Treatment > 60 Days

< 20%

Breast Cancer

20.a. Abnormal Screening Results with Complete Follow-Up > 90%

25.d. Abnormal Screening Results; Time from Screening to Diagnosis > 60 Days

< 25%



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Diagnostic Indicators

26 Treatment Started for Breast Cancer > 90%

27.d. Breast Cancer; Time from Diagnosis to Treatment > 60 Days < 20%

the program performance through Minimum Data Elements (MDE’s), which are quality assurance measures. MDE’s contain screening and diagnostic data that is submitted in April and October of each year. The NBCCEDP has set core performance indicators with benchmarks to ensure timely, complete, and accurate data is collected so we can better serve clients in the WHC.

Breast Core Performance Indicators

Indicator Type Indicator Description CDC Benchmark

Screening Mammograms provided to women > 50 years of age > 75%

Completeness of Clinical Follow-up

Abnormal screening results with complete follow-up > 90%

Diagnosed cancers with treatment initiated > 90%

Timeliness of Clinical Follow-up

Abnormal screening results: Time from screening to diagnosis within 60 days

> 75%

Breast Cancer: Time from diagnosis to treatment within 60 days > 80%

Cervical Core Performance Indicators

Case Management Services

Case Management Services The WHC provides case management services to ensure that patientsclients receive timely and appropriate screening and diagnostic services. WHC does not reimburse for treatment services. If a woman diagnosed with cancer and not eligible for Medicaid services, WHC will refer to other treatment resources. and if necessary, treatment services. Staff will explain the importance of follow-up services, and assist with scheduling appointments. Case management services will also assess the clientpatient for barriers that could possibly hinder theher from client to keeping follow-up appointments and takinge action on recommendations. Case management services conclude when a clientpatient is determined to have a final diagnosis not requiring treatment or when a clientpatient initiates or refuses treatment, refuses treatment., or is no longer eligible for WHC. Responsibilities of Case Management

WHC Care Coordinators work closelyconduct an assessment with the clientpatients to ensure

that the clientpatient receives the appropriate services in a timely manner

Coordinate the clientpatient’s care with provider(s)

Review clinical records for appropriateness of recommended care

Ensure recommended diagnostic procedures are completed within time frames







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Maintain timely contact with clientpatients and documenting all contacts using a tracking system using a tracking system

Assess clientpatients for barriers and provide assistance (Transportation, work schedule, etc.)

If diagnosed with cancer, assist clientpatient with Medicaid application and track Medicaid

approval, and or refer to other treatment resources

Responsibilities: WHC and Providers

WHC Responsibilities to Providers: Ensure provider contracts are established

Provide training, technical assistance, and professional education resources to enrolled providers

Provide WHC enrollment forms, reporting forms, and promotional materials

Ensure all providers meet quality standards. i.e. MQSA CLIA

Reimburse providers for screening and diagnostic services within 30 days of reimbursement

Ensure case management services are provided to eligible women

Refer eligible women to treatment services

Maintain ongoing provider communication in regards to policies and procedures.

Maintain a central patient tracking system

Provider Responsibilities to WHC:

Providers must attend WHC orientation training

Providers are responsible for following WHC eligibility screening protocols

Enrollment form must be completed and signed by patient and submitted with the initial screening visit within 30 days of initial screening date

Ensure that patients receive eligible screening and diagnostic services covered under the program

Notify patient verbally or in writing of results within 10 days of receiving results and explain abnormal results and processes to obtain diagnostic services

According to NRS 457, providers MUST report all cancer diagnoses to the Cancer Registry http://www.leg.state.nv.us/NRS/NRS-457.html

Provide patients with educational materials and recommendations for breast and cervical cancer screening intervals as per screening guidelines as well as the importance of importance of timely follow-up of diagnostic procedures.

Additional screening results must be submitted within 30 days of procedure date

All abnormal results must be faxed within 48 hours to ensure timely follow-up and to initiate case management services

Diagnostic results must be submitted within 48 hours of procedure date

If a woman refuses diagnostic procedures/treatment, the Patient Refusal Form must be completed and faxed to WHC within 48 hours of form signed

All billing claim forms must be submitted within 30 days of the date of service

Ensure patients are not be billed for reimbursable program services

Ensure women are recalled and screened at appropriate screening intervals (WHC will not

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Commented [MDM2]: Yes Case Management includes assistance for dissolving barriers


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reimburse for unnecessary “over-screening”

Maintain patient confidentiality

Assemble documents for provider site audits

Initial screening visit form must be completed and signed by the clinician and submitted within 30 days of the date of service

Eligibility Screening & Enrollment

Determining Eligibility WHC expects providers to encourage eligible women to pursue health insurance coverage. Federal law mandates that the WHC Program is the "payor of last resort." If breast and cervical cancer services are available through any other state compensation program, under an insurance policy or federal or state health benefits program, prepaid health services, WHC funding may not be used.

WHC eligibility components:

Must be at least 21 years of age Must be at or below 250% of

federal poverty level (see chart) Nevada Resident Underinsured

Transgender women (male to female) 40 years and above who have taken or are taking hormones can receive breast cancer screening services

Transgender women (female to male) 21 years and above who have not undergone bilateral breast mastectomy and hysterectomy can receive breast and/or cervical cancer screening services

Underinsured Policy

The intent of the underinsured policy is to relieve financial burdens which may prevent the patient from receiving cancer screening or diagnostic testing. WHC will reimburse at Medicare’s allowable rate. If the provider accepts payment from WHC there should be no outstanding balance to the patient.

A patient covered under a health insurance plan that does not fully cover breast and cervical cancer screenings and/or diagnostics and has an insurance deductible of $100.00 or more is considered underinsured under the WHC policy. Underinsured status also includes co-pays for covered breast and cervical cancer screenings.

Guidelines:

Fiscal Year 20198 Income Guidelines

Number of People in Household

Household Income Before Taxes

Yearly 250% FPL Monthly 250% FPL

1 $30,35030,150 $2,52913

2 $41,15040,600 $3,429383

3 $51,950,050 $4,329254

4 $62,7501,500 $5,229125

5 $73,5501,950 $6,1295,996

6 $84,3502,400 $7,0296,867

7 $95,15092,850 $7,9297,738

8 $105,95003,300 $8,829608

For each additional person, add $4,3204,180 per year

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Underinsured women must be deemed eligible for WHC services by Access to Healthcare

Network (AHN) prior to deductible or co-pay reimbursement

WHC will reimburse providers for deductibles and co-pays for WHC covered services

WHC will reimburse providers at the Medicare allowable rates

Reimbursable providers must be part of WHC provider network

Complete Cancer Registry Information section for those clients diagnosed with cancer Ensure National Breast and Cervical Cancer Early Detection Program final diagnosis and treatment time frames are met

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Program Responsibilities

WHC Responsibilities

The WHC has the following responsibilities to WHC providers:

Ensure provider contracts are established

Provide training, technical assistance, and professional education resources to enrolled providers Provide WHC enrollment forms, reporting forms, and promotional materials

Develop reporting requirements Ensure all provider meet Quality standards. i.e. mammography facilities have Mammography

Quality Standards Act (MQSA CLIA) certification Ensure all laboratories have Clinical Laboratory Improvement Amendments (CLIA) certification

Reimburse providers for screening and diagnostic services within 30 days of reimbursement request Ensure case management services are provided to eligible women

Refer eligible women for treatment services Maintain ongoing provider communication in regards to policies and procedures., and screening data

Maintain client confidentiality Maintain a central client tracking system

Set, monitor, and maintain assurance standards

Submit data to the NBCCEDP for evaluation

Provider Responsibilities Enrolled WHC providers have the following responsibilities to the WHC:

Providers must attend WHC orientation training Providers are responsible for following WHC eligibility screening protocol

Clients must undergo eligibility verification before receiving screening/diagnostic services paid for by WHC

Providers should encourage eligible women to enroll in an insurance product through the ACA or Expanded Medicaid

Enrollment form must be completed and signed by client and submitted with initial screening visit form within 30 days of initial screening date


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Ensure that clients receive eligible screening and diagnostic services covered under the program Notify women, orally or in writing, of results within 10 days of result receipt and explain abnormal

results and the process for obtaining diagnostic services Providers MUST report all cancer diagnosis to the Cancer Registry


Provide clients with education and recommendation for breast and cervical cancer screening intervals as per screening guidelines as well as educated on the importance of timely follow-up of

diagnostic procedures. Initial screening visit form must be completed and signed by clinician and submitted within 30 days of

initial screening date

Provide clients with education and recommendation for breast and cervical cancer screening intervals as per screening guidelines

Educate clients on the importance of timely follow-up of diagnostic procedures after receiving abnormal results

Additional screening results must be submitted within 30 days of procedure date Ensure clients with abnormal or inadequate screening results receive timely follow up services as per

screening guidelines All abnormal results must be faxed within 48 hours to ensure timely follow-up and to initiate case

management services Diagnostic results must be submitted within 48 hours of procedure date

If a women refuses diagnostic procedures/treatment, the Client Refusal Form must be completed and faxed to WHC within 48 hours of date signed

All billing claim forms must be submitted within 30 days of service date Ensure clients should not be billed for reimbursable program services

Ensure women are recalled and screened at appropriate screening intervals (WHC will not reimburse for unnecessary “over-screening”

Maintain client confidentiality Assemble documents for provider site auditsInitial screening visit form must be completed and signed by

clinician and submitted within 30 days of initial

Initial screening visit form must be completed and signed by clinician and submitted within 30 days of initial


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Eligibility Screening & Enrollment

Determining Eligibility The WHC expects providers to encourage eligible women to pursue health insurance coverage. Federal law mandates that the WHC Program is the "payor of last resort." If breast and cervical cancer services are available through any other state compensation program, under an insurance policy, under a federal or state health benefits program, or prepaid health service, funding may not be used.

In the past, WHC eligibility was based on the client self-reporting their income and residency at their provider office during their breast and cervical cancer screening appointment. Due to healthcare reform and the Medicaid expansion, WHC must now verify eligibility. Federal law mandates that the WHC Program is the "payor of last resort." If breast and cervical cancer services are available through any other state compensation program, insurance policy, federal or state health benefits program, or prepaid health service (with the exception of Indian Health Services), funding may not be used.

WHC eligibility components:

Be at least 21 years of age and above Must fall within 250% of federal poverty level (see chart) Be a Nevada Resident Underinsured Transgender women (male to female) 40 years and above who have taken or are

taking hormones can receive breast cancer screening services Transgender women (female to male) 21 years and above who have not undergone

bilateral breast mastectomy and hysterectomy can receive breast and/or cervical





1 $30,150 $2,513

2 $40,600 $3,383

3 $51,050 $4,254

4 $61,500 $5,125

5 $71,950 $5,996

6 $82,400 $6,867

7 $92,850 $7,738

8 $103,300 $8,608

For each additional person, add $4,180 per year

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cancer screening services





1 $29,425 $2,452

2 $39,825 $3,318

3 $50,225 $4,185

4 $60,625 $5,052

5 $71,025 $5,918

6 $81,425 $6,785

7 $91,825 $7,652

8 $102,225 $8,518

For each additional person, add $4,160 per year

Underinsured Policy

A person covered under a health insurance plan that does not fully cover breast and cervical cancer screenings and/or diagnostics and has an insurance deductible of $100.00 or more is considered underinsured under the WHC policy. Underinsured status also includes co-pays for covered breast and cervical cancer screenings.

Guidelines: Underinsured women have to be determined eligible for WHC services by Access to

Healthcare Network (AHN) prior to deductible or co-pay reimbursement.

WHC will reimburse providers for deductibles and co-pays for WHC covered services.

WHC will reimburse providers at the Medicare allowable rates.

Reimbursable providers must be a WHC provider. Steps to Reimbursement:

1. Providers will bill clientpatient’s insurance company first.

2. If the clientpatient has an outstanding balance following insurance billingprocessing, the

clientpatient will contact Access to Healthcare Network for eligibility verification and

enrollment in to Women’s Health Connection.WHC

3. ClientPatient will submit bill(s) to AHN for reimbursement to the provider(s).

The intent of the policy is to relieve financial burdens which may prevent the client from getting screened for cancer or following through with diagnostic tests. WHC will pay the allowable Medicare rate for services. If the provider accepts payment from WHC, there should be no outstanding balance to the client following the payment

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Must be Nevada resident Are uninsured. Women may be eligible to receive federal financial assistance when purchasing health insurance if income level is between 139% and 400% of the Federal Poverty Level (FPL) through the Health Insurance Marketplace Are underinsured Underinsured is defined as:

Having health insurance that does not cover cancer screening or diagnostic services

Being a Medicare beneficiary and not having Part B

Having health insurance that does not provide coverage for breast or cervical cancer screening

Having health insurance with an annual deductible (greater than $2,500), monthly spend down, or co-payment that is high enough to prevent client from obtaining cancer screening services Have no Medicaid. Women may be eligible to apply for Medicaid coverage if income level is at or below 138% FPL Transgender women (male to female) 21 years and above who have taken or are taking hormones can receive breast cancer screening services

Program eligibility can be determined by the provider at the time the client is seen. Those who do not meet the eligibility requirements should be referred to other agencies for assistance. Program eligibility must be determined each year of program

participation. Methods of Enrollment into WHC Program No Wrong Door Model

To verify eligibility, clients must complete the “Presumptive Eligibility Form” and provide proof of age, residency and income to the program. Some women will be able to provide this information at their provider’s office during their screening appointments and others will provide this information to AHN prior to making their screening appointments.1. Enrollment at the PCP’s Office

A Womaen enrolls into WHC in the program by completing the Women’s Health ConnectionWHC Enrollment Form. As a participating provider for the WHC Program it is your responsibilityThe provider shall to determine eligibility based on a woman’s age, income and insurance status. A woman is considered enrolled in WHC Program on the date screening services are performed, not before. date that eligible screening services were performed and not before. WHC will not pay for services prior to the enrollment date. performed before the date of service at the provider’s office.

2. Enrollment through the AHN Helpline Call Center A woman who established eligibility for thethrough WHC through the AHN Helpline, will receive a welcome letter in the mail in the mail a welcome letter, list of participating providers, and the WHC Enrollment Form. When the clientpatient arrives at the PCP’s office for her scheduled appointment she should present the partially completed WHC Enrollment Form (page 1 of the form). A woman is considered enrolled in WHC Program on the date that eligible screening services were performed and not before.



Commented [BJE(5]: Are you placing any parameters on this? Some grantees are using a sliding scale or some method to determine what is prohibitive.

Commented [MDM6]: Yes, the annual deductible must be greater than $2,500.

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WHC will not pay for services performed before the date of service at the provider’s office.

Women’s Health Connection Member ID Card Every woman screened must be assigned a card. To assist verify a patient’s enrollment in WHC, contracted providers to ensure enrollment is established in WHC, please advise every woman to present this card to the provider at the time of each secondary appointment.

Card for women ages 40-64:


Card for the CAP program

Through the “No Wrong Door Model” WHC hopes to provide multiple entry ways to determine a woman’s eligibility for the program. Door #1: Clients are screened for eligibility through the AHN call center. Door #2: Client calls provider for an appointment, provider assumes presumptive eligibility for WHC program and directs women to call center for eligibility screening. Door #3: AHN screens clients for eligibility in person at the AHN office in the North. Door #4: Client eligibility is verified at Federally Qualified Health Centers (FQHCs), Local Health Authorities (LHA), Community Health Nurses (CHN) and select private providers. The eligibility screening process affects primary care providers only.


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Emergency Situations

Clients who complain of the following symptoms may be immediately enrolled into the program, even if they are eligible for Medicaid or Nevada Health Link: Breast pain (“mastalgia”): without or without associated mass Palpable breast mass with or without pain Abnormal breast skin findings: ecchymosis, erythema, peau d’orange skin changes, or ulceration of the skin Abnormal nipple findings: nipple discharge, nipple retraction Please instruct clients experiencing an emergency situation to contact WHC immediately at 775-284-1904. Eligibility Screening Protocols DOOR # 1: AHN CALL CENTER

Clients call AHN call center

WHC Presumptive Eligibility form is completed by AHN call center staff

Client will fax, email, or mail verification documents o Clients have 10 business days to submit documentation to AHN call center. o WHC care coordinators follow up with client on day 5 and day 10 if documents are not received within 5 business days o Appointment with provider will not be made until documentation is received and eligibility is determined

WHC care coordinators will communicate approval status with patients and providers. o Eligibility forms and WHC member card will be mailed to client DOOR #2: PROVIDER PRESUMES ELIGIBILITY, REFERS CLIENT TO AHN CALL CENTER A woman calls her provider office to schedule a breast/cervical cancer screening appointment.

Provider’s office presumes client’s eligibility over the phone

Client self-reports income, NV residency, age, insurance status o If client is presumed eligible, she is referred to AHN call center. Call center will verify eligibility (Door #1) o If client shows up her appointment before eligibility has been determined by AHN, client will not be seen

Client will need to be referred to AHN for eligibility screening DOOR #3: CLIENT ELIGIBILITY IS DETERMINED IN PERSON AT ACCESS TO HEALTHCARE NETWORK IN RENO, NEVADA

Client calls the call center and presumptive eligibility is established

Client wishes to enroll into the WHC program in person at AHN office in Reno

Call center makes appointment, AHN care coordinators meet with women in person and client presents all verification documentation

Eligibility is verified by WHC care coordinators at AHN office.

Once eligibility is verified WHC care coordinator provides client with yellow WHC Member card and enrollment form to take to provider

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Commented [BJE(7]: Eligible but not enrolled at the time of presentation. May want to clarify.



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Commented [BJE(8]: So providers do not have the ability to verify eligibility at their offices? It seems like an extra hoop to jump through for a woman to then have to call the call center.

Commented [MDM9]: This is true for women who are being screened at sites that are referring their eligibility screening to AHN.



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DOOR #4: CLIENT ELIGIBILITY IS DETERMINED BY PROVIDER AT FQHCs, LHAs, CHNs, AND SELECTED PRIVATE PROVIDER OFFICES Step 1: Verification Documentation

Clients will need to complete WHC Presumptive Eligibility Form, provide age, residency and income verification documents at their screening appointment. Door 24 providers will retain all verification documents and fax Presumptive Eligibility to AHN where the data will be entered into CaST. Door 2 4 providers will continue to provide the “WHC Member Card” to enrolled clients.

All clients must complete the WHC Presumptive Eligibility Form (appendix A). Door 24 providers will mark the Presumptive Eligibility Form with the action taken and submit the form to AHN for every client who attempts to enroll into WHC program. AHN will follow up with these clients to ensure insurance and screening appointments are obtained within 45 days from initial contact. If clients are still without coverage after 45 days, AHN or provider may enroll clients into WHC program.

AGE (one of the following) Residency (one of the following) Income (one of the following)

Government Issued

Picture ID

Nevada Driver’s License

Nevada State ID

Passport/ foreign Country ID

Legal Birth Certificates

INS Papers/ Permanent

Residence Card

Government Issued

Picture ID

Nevada Driver’s License

Nevada State ID

Utility bill

Dependent Support Form

(Appendix C)

Verification income

(employment letter)

Pay Stub

unemployment Statement

Welfare, TANF, Mental Health

Tribal, and any benefits

Dependent Support Form

(Appendix C)

Step 2: Medicaid or ACA Enrollment Referrals

Providers will determine if women applying for the WHC program are eligible for Medicaid expansion or an ACA insurance product through Nevada Health Link. Medicaid Eligible Clients are eligible for Medicaid if their income is at or below 138% of the FPL, are a US citizen, and a Nevada Resident. Medicaid enrollment is opened year round. Clients who are eligible for Medicaid enrollment will not be enrolled into the WHC program immediately.

Commented [BJE(10]: Will this be true for the new CHA pilot? Or does there need to be a 5th option for that? I’m guessing AHN will not be entering MDE data for women served through the direct contract with CHA.

Commented [MDM11]: The CHA pilot will operate as a Door 4 provider. They will be doing their own data entry. July 1, CHA will begin Door 4 screening following this model.






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Screening providers will refer Medicaid eligible clients to the Medicaid office or an enrollment

assistance agency to apply for coverage. Medicaid eligible clients will not be enrolled into

WHC program. Clients who are pending Medicaid coverage will not be enrolled into the WHC

program.

Nevada Health Link Eligible

Clients are eligible for an ACA insurance product if their income 139% - 400% of the FPL, have U.S. citizenship, and are Nevada residents. Clients

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Commented [BJE(12]: Is there any way to measure how many women are turned away from the program to apply for Medicaid? Same thing with NHL.


Commented [MDM13]: Yes, during compliance site visits, the number of women navigated toward Medicaid will be accounted for.


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applying for an ACA insurance product through the Nevada Health Link may qualify for a subsidized

insurance rate. Clients eligible for Nevada Health Link will be

referred to apply for an ACA insurance product during an open enrollment period. Nevada Health

Link open enrollment is as follows: November 1, 2016: Open enrollment starts –

first day to enroll in marketplace plan January 1, 2017: First date coverage can start

January 31, 2017: Open enrollment ends


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Women’s Health Connection Member ID Card WHC can only provide breast and cervical

screening services to Nevada women each year based on federal funds received through the NBCCEDP. Every woman screened must be

assigned a card. To assist contracted providers to ensure enrollment is established in WHC,

please advise every woman to present this card to the provider at the time of each secondary

appointment.



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170001

Expires 6/29/2017 FISCAL ENDS:

8

8


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Commented [GS14]:



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170001

Expires 6/29/2017

Annual pelvic exam and abnormal follow-up

FISCAL ENDS:

FISCAL ENDS:

8

8

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8


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Underinsured Policy

A person covered under a health insurance plan that does not fully cover breast and cervical

cancer screenings and/or diagnostics and has an insurance deductible of $500.00 or more is

considered underinsured under the WHC policy. Underinsured status also includes co-pays for covered breast and cervical cancer screenings.

Guidelines:

Underinsured women have to be determined

eligible for WHC services by Access to

Healthcare Network (AHN) prior to deductible or

co-pay reimbursement.

Women must meet WHC requirements of 250%

or below Federal Poverty Level (FPL).


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Commented [BJE(15]: This looks good to me. Is there a plan to measure how many underinsured women enroll and are served? This is important to know how big this issue is.


Commented [MDM16]: Yes, all this information will be tracked in the reimbursement module of Cast.





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Women must meet the age requirements of 21 –

64 years of age for cervical cancer screening

services.

Women must meet the age requirements of 40 –

64 for clinical breast exams or 40 – 64 for

mammograms.

WHC will reimburse providers for deductibles

and co-pays for WHC covered services.

WHC will reimburse providers at the Medicare

allowable rates.

Clients with abnormal results will be case

managed by AHN staff.

Reimbursable providers must be a WHC

provider.


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Steps to Reimbursement:

1. Provider will bill client’s insurance company first.

2. If the client has an outstanding balance

following insurance billing, the client will contact

Access to Healthcare Network for eligibility

verification and enrollment in to Women’s

Health Connection.

3. Client will submit bill(s) to AHN for

reimbursement to the provider(s).

The intent of the policy is to relieve financial burdens which may prevent the client from

getting screened for cancer or following through


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with diagnostic tests. WHC will pay the allowable Medicare rate for services. If the provider accepts payment from WHC, there

should be no outstanding balance to the client following the payment.


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Reimbursable Screening Services

Breast Screening Services reimbursed by WHC A Womaen 40 years of age or older, enrolled in WHC, are eligible to receive the following services annually:

40 – 49 years: Clinical breast exam (CBE) only, not eligible for a screening mammogram 40 – 49 years: If CBE is abnormal, WHC will reimburse for diagnostic mammogram or

ultrasound

4050 years and older: Clinical breast exam and screening mammogram Screening mammograms must be ordered for all clientpatients aged 450 years and over

using the WHC Mammography and Ultrasound Referral Form. The form must include the results of the clinical breast exam and be signed and dated by the ordering clinician.

o

Cervical Screening Services reimbursed by WHC Women 21-64 years of age enrolled in WHC shall receive the following services annually or as indicated by the clinician:

21-29 years old: o Pelvic exam o Pap Test

o Every 3 years, unless there is an abnormal result o Diagnostic services after an abnormal screening result o Referral for treatment

30-64 years old: o Pelvic exam o Co-test (Pap and HPV)

o Every 5 years, unless there is an abnormal result o Diagnostic services after an abnormal screening result o Referral for treatment

Referral for treatment

Cervical cancer screening is not recommended for women older than age 65 who have had adequate screening and are not at high risk. If a woman over the age of 64 needs to be screened and is eligible to receive Medicare benefits, but is not enrolled, she should be encouraged to enroll in Medicare. Women enrolled in Medicare Part B are not eligible for the WHC.

WHC will pay for a PCP visit under the following circumstances:

WHC will pay for a Pap test or co-testing on women who have had a hysterectomy with or without removal of the cervix if the hysterectomy was due to cervical cancer

WHC will pay for a Pap test or co-test for women who have had a hysterectomy without removal of the cervix

If a Pap test or co-test is unsatisfactory or /false-positive the patient should have a . rRepeat test immediately. should occur immediately. The unsatisfactory result is not to be considered in the Pap (3 year) and co-testing (5 year) period offor the cervical cancer screening schedule


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If patient presents new breast symptoms before annual screening date

To offer a second office visit to another PCP if the first visit was unsatisfactory

All office visits should be billed through the standard office visit CPT codes: 99201-99203 for “new patients” and 99211-99213 for “established patients”. A “new patient” is defined as a woman who is new to the WHC and/or is at their first annual appointment with the WHC. If the patient hasn’t been seen within three years they are considered a new patient. If less than three years they are considered an established patient. CPT codes 99204, 99205 and 99214 are not appropriate for WHC screening visits

WHC will not pay for a PCP visit under the following circumstances:

To discuss normal screening results (including mammogram with BIRADS 0-3)

If a clientpatient returns to her existing provider and is not eligible for a screening test, and the provider performs a screening test anyway, WHC will NOT pay for the office visit or the lab fee for the screening test

WHC will not pay for an initial mammogram screening mammogram without a CBE corresponding performed performed CBE.clinical breast exam

Annual Breast and Cervical Cancer Screening Visit Form

Review clientpatient history from page 1 (PresumWHCptive Eligibility Enrollment Form)

Fill out the Clinical Breast Exam Findings section

o CAll clients ages 40 and above are eligible to receive an annual clinical breast exam

o If there is an abnormal finding, refer clientpatient for diagnostic services. Complete Mammography and Ultrasound Referral Form. Imaging results must be reviewed by clinician before referral to breast specialist

Fill out the Reason for Imaging section

o If the clientpatient is eligible for a routine screening mammogram (540 years and above), complete Mammography and Ultrasound Referral Form

o If the clientpatient is eligible for diagnostic services (40 years and above) due to abnormal clinical breast exam findings, complete Mammography and Ultrasound Referral Form. Results must be reviewed by clinician before referral to breast specialist

o For breast specialist referral, complete Breast Specialist Referral Form

Fill out the Pelvic Exam Findings section

o All clientpatients are eligible to receive an annual pelvic exam, unless the woman had a total hysterectomy not due to cervical cancer

o If an abnormal pelvic is noted that is referred to the cervical specialist, describe the abnormality in the notes field of the form

o If an abnormal pelvic is noted that is not referred to the cervical specialist, describe the abnormality in the notes field of the form

o For cervical specialist referral, complete Cervical Specialist Referral Form

Fill out the Reason for Pap/HPV Test section

o Co-testing (Pap and HPV test) is the recommended method for cervical cancer screening

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PLEASE NOTE: Mammography and

Ultrasound Referral Form areis valid for 60 days after

date of issue by PCP, otherwise client patient must wait until her next annual screening visit for

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o The WHC Program will reimburse Pap tests every 3 years and co-testing (Pap and HPV test) every 5 years after normal Pap results for women who have an intact cervix, or for women who have had a hysterectomy due to cervical neoplasia

Clinician should discuss exam results with clientpatient and indicate any concerns in the notes field

Any test results must be delivered orallyverbally or in writing to clientpatients within 10 days of test result receipt Clinician must sign and date the bottom of the page

All original WHCPresumptive Eligibility Enrollment and Annual Screening Visit Forms must be submitted signed and dated to the appropriate WHC office within 30 days of date of service

All AWHC Enrollment nnual Screening Visit Forms with abnormal findings must be faxed to WHC within 48 hours upon receipt of any abnormal screening results- Fax 775-284-1918

o Fax all reports to 775-284-1918

Any test results must be delivered orally or in writing to client within 10 days of test result

receipt





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Reimbursable Diagnostic Services

If a woman receives an abnormal screening test at any time, the appropriate diagnostic workup must be completed within 60 days from the date of the abnormal test. The woman will be assigned a a WHC Care Coordinator, to assist with the diagnostic workup process and to ensuringe a final diagnosis is reached and treatment is initiated. WHC Care Coordinators can be reached at 844-469-4930.

Breast Diagnostic Services reimbursed by WHC A wWomen 450 years of age and older enrolled in WHC shall receive diagnostic services with for the following screening results:

Normal CBE and Abnormal Screening Mammography Test Results

BI-RADS Category 0 (Assessment Incomplete) – Additional imaging is required

BI-RADS Category 3 (Probably Benign) – If this is the first ever mammogram, additional imaging is required. Initial short-interval follow-up examination (specialist visit and mammogram), usually in 6 months, followed by another examination in 6 months, then annually with PCP until stability is demonstrated for a minimum of 2-3 years. Category 3 is not recommended for screening mammograms; it is intended for use with diagnostic mammograms only. If this is not the first ever mammogram, previous results should be reviewed before further diagnostic evaluation is determined( Please refer to breast algorithm for further follow up, located as an attachment)

BI-RADS Category 4 (Suspicious Abnormality) – Refer to specialist BI-RADS Category 5 (Highly Suggestive of Malignancy) – Refer to specialisspecialist t

Women 40 years and older enrolled in WHC shall receive diagnostic services with the following screening results:

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Abnormal CBE and Diagnostic Evaluation (Mammogram and Ultrasound) Test Results

BI-RADS Category 0 (Assessment Incomplete) – Additional imaging is required

BI-RADS Category 1 (Negative) – If certain of abnormality or mass is persistent refer to specialist. If not certain of abnormality, repeat CBE in 30 days by PCP, if mass is not persistent follow routine screening, if mass is persistent refer to specialist

BI-RADS Category 2 (Benign) – Correlate physical findings with diagnostic imaging evaluation and assure finding is concordant, if finding is concordant follow routine screening, if finding is discordant, refer to specialist

BI-RADS Category 3 (Probably Benign) – Refer to specialist

BI-RADS Category 4 (Suspicious Abnormality) – Refer to specialist BI-RADS Category 5 (Highly Suggestive of Malignancy) – Refer to specialist

Other Breast Diagnostic Services

Consultant-Repeat CBE

Surgical consultation

Mammary ductogram or galactogram single duct

MRI with or without contrast. Breast MRI can be reimbursed in conjunction with a mammogram when a clientpatient has a BRCA mutation, a first-degree relative who is a BRCA carrier, or a lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO that are largely dependent on family history. Breast MRI can also be used to better assess areas of concern on a mammogram or for evaluation of a clientpatient with a past history of breast cancer after completing treatment. Breast MRI should never be done alone as a breast cancer screening tool. Breast MRI cannot be reimbursed for by the program to assess

Important! IMPORTANT! Specialist Referrals

o WHC Care Coordinator will selectchoose specialist to , process the referral. Once referral has been processed WHC will notify PCP, .and notify the schedule specialist visit information to PCP.

o WHC Care Coordinator will process specialist referral o WHC Care Coordinator will notify the scheduled specialist visit

information to PCP

Abnormal CBE results include: Discrete palpable mass suspicious for cancer, Bloody/serous nipple discharge, Nipple/areolar scaliness, and Skin dimpling/retraction


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the extent of disease in a woman who is already diagnosed with breast cancer - Prior approval required

Biopsy (Fine Needle biopsy (FNA), core needle biopsy, and excisional biopsy) Some pre-operative testing is allowed with prior approval from WHC. These procedures

should be medically necessary for the planned surgical procedure

Breast Specialist Services WHC will pay for a consultation with a specialist under the following circumstances:

To discuss follow-up if CBE is normal and screening imaging results are BI-RADS 4 or BI-RADS 5

To discuss follow-up if CBE is abnormal and diagnostic imaging results are BI-RADS Category 0, 3, 4,& 5

All consultation visits should be billed through the standard office visit CPT codes: 99201-99205 for “new patients” and 99211-99214 for “established patients”. A “new patient” is defined as a woman who is new to the WHC and/or is at their first annual appointment with the WHC. If the patient hasn’t been seen in three years they are considered a new patient. If less than three years they are considered an established patient. Consultations billed as 99204 or 99205 must meet the criteria for these codes of moderate complexity for 45 minutes or high complexity for 60 minutes, respectively, during a new patient visit. A summary report of this visit must be attached to the reimbursement request

WHC will not pay for a consultation with a specialist under the following circumstances:

To discuss normal/benign screening results dependingbased on global period

If diagnostic imaging is not performed before initial specialist visit. All imaging results must be presented at time of initial visit

An office visit that is billed concurrently with a procedure will not be reimbursed through the WHC

Post-op office visit (This is included in the procedure reimbursement)

If the pPurpose of office visit is for treatment

For clientpatients who have a BI-RAD Category 0 – Assessment Incomplete mammogram result and additional imaging is recommended, WHC will not pay for an office visit to give the clientpatient another referral form for the additional imaging. The PCP shallneeds to fax the Mammography and Ultrasound Referral Form ordering the additional imaging to the imaging facility following verbal notification to the clientpatient

To discuss mammogram results which are paid through another payment sources other than WHC

To discuss diagnostic or treatment plans for non-WHC covered health conditions

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WHC does not pay for breast cancer treatment services. WHC will assist with referral to Medicaid (eligible under the Medicaid Treatment Act) or other treatment resources.

Schedule for follow-up/return visits:

Once a diagnostic workup has been completed, WHC will pay the specialist for one short term follow-up visit. Short-term is defined as 6 months from the date of last specialist visitbiopsy result. The Clientpatient must have imaging performed prior to the short term follow up with the specialist if their initial mammogram was a BI-RAD 3. If the results from that visit are negative, normal, or benign and not suspicious for cancer, the clientpatient must resume normal screening with a PCP.

ClientPatients may be referred into WHC for a diagnostic follow-up by a PCP if they have had a prior mammogram by a non-program payment source which yielded an abnormal result, and they meet program eligibility requirements. A clinical breast exam must be performed and a copy of the abnormal mammogram results must be included in the medical records before referral to specialist.

Breast Specialist Referral Form Review PCP section of the form for CBE findings and imaging results

Only the initial visit requires a referral from the PCP. F, for each additional visit, a new Breast Specialist Referral Form must be completed

Indicate if the office visit is a repeat CBE exam or a surgical consultation

Indicates the type of recommended/performed diagnostic procedure(s)

Indicate the final diagnosis

Indicate date of service date(s)

Complete treatment status information

Specialist should discuss exam results with clientpatient and indicate any concerns in the notes field

Specialist must sign and date the bottom of the page All completed Breast Specialist Referral Forms must be faxed to WHC within 48 hours of office

visit at 775-284-1918 to ensure timely and adequate follow-up

All original Breast Specialist Referral Forms must be submitted by mail to the appropriate WHC

office within 30 days of date of service All completed Breast Specialist Referral Forms must be faxed to WHC within 48 hours of office

visit at 775-284-1918 to ensure timely and adequate follow-up

Any test results must be delivered orally verbally or in writing to clientpatients within 10 days of test result receipt

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Cervical Diagnostic Services reimbursed by WHC A wWomen 21 years and older enrolled in WHC shall receive diagnostic services with for the following screening results:

Abnormal Pelvic Exam Results

Abnormal cervix (Suspicious for cervical cancer) – Refer to specialist Abnormal cervix (Not suspicious for cancer) – Refer to specialist

Abnormal Co-Test (Pap and HPV) Screening Results

ASC-US -– Atypical squamous cells of undetermined significance Pap test with positive HPV test - Refer to specialist for colposcopy

ASC-H -– Atypical squamous cells cannot exclude HSIL Pap test with negative or positive HPV test– Refer to specialist for colposcopy

LSIL -– Low grade squamous intraepithelial lesion Pap test with negative or positive HPV test - Refer to specialist for colposcopy or LEEP

HSIL - High grade squamous intraepithelial lesion Pap test with negative or positive HPV test - Refer to specialist





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Squamous cell carcinoma Pap test with negative or positive HPV test – Refer to specialist for biopsy and further evaluation

AGC -– Atypical glandular cells Pap test with negative or positive HPV test – Refer to specialist for colposcopy with endometrial sampling

AIS -– Endocervical adenocarcinoma in situ Pap test with negative or positive HPV test – Refer to specialist for colposcopy

Adenocarcinoma Pap test with negative or positive HPV test – Refer to specialist for biopsy and further evaluation

Positive HPV and Negative Pap -– Repeat co-test in 1 year

Abnormal Pap test Screening Results

ASC-US – Atypical squamous cells of undetermined significance – Repeat test in 1 year

ASC-H – Atypical squamous cells cannot exclude HSIL – Refer to specialist for colposcopy

LSIL – Low grade squamous intraepithelial lesion - Refer to specialist for colposcopy

HSIL - High grade squamous intraepithelial lesion – Refer to specialist for colposcopy

Squamous cell carcinoma – Refer to specialist for biopsy and further evaluation

AGC – Atypical glandular cells – Refer to specialist for colposcopy with endometrial sampling

AIS – Endocervical adenocarcinoma in situ – Refer to specialist for colposcopy

Adenocarcinoma – Refer to specialist for biopsy and further evaluation

Other Cervical Diagnostic Services

Repeat pelvic exam

Repeat unsatisfactory Ppap test

Colposcopy (with or without biopsy)

Local excision of lesion (polyp)

Endocervical Curettage (ECC)

Cold Knife Conization (CKC) - Prior approval required

LEEP - Prior approval required

Endometrial biopsy - Prior approval required Some pre-operative testing is allowed with prior approval. These

procedures should be medically necessary for the planned surgical procedureSome pre-operative testing is allowed with prior approval. These procedures should be medically necessary for the planned surgical procedure

Cervical Specialist Services WHC will pay for a consultation with a specialist under the following circumstances:

To discuss diagnostic follow-up after an abnormal pelvic exam

To discuss diagnostic follow-up after an abnormal Co-Test or abnormal Pap test


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All consultation visits should be billed through the standard office visit CPT codes: 99201-99205 99205 for “new patients” and 99211-99213 for “established patients”. A “new patient” is defined defined as a woman who is new to the WHC and/or is at their first annual appointment with the the WHC. If the patient hasn’t been seen in three years they are considered a new patient. If less less than three years they are considered an established patient. Consultations billed as 99204 or 99204 or 99205 must meet the criteria for these codes of moderate complexity for 45 minutes or or high complexity for 60 minutes, respectively, during a new patient visit. A summary report of this visit must be attached to the claim.reimbursement request

WHC will not pay for a consultation with a specialist under the following circumstances:

To discuss normal screening results

An office visit that is billed concurrently with a procedure will not be reimbursed through the WHC

Post-op office visit (This is included in the procedure reimbursement)

Purpose of office visit is for treatment

To discuss screening results which are paid through another payment sources other than WHC

To discuss diagnostic or treatment plans for non-WHC covered health conditions WHC does not pay for cervical cancer treatment services. WHC will assist with referral to Medicaid

(eligible under the Medicaid Treatment Act) or other treatment resources

Schedule for follow-up/return visits:

Surveillance after one year following a positive HPV test and negative Pap test For the management of women with abnormal screening results the program follows the

American Society for Colposcopy and Cervical Pathology (ASCCP) recommendations. Please follow the link for recommendations:

http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx ClientPatients may be referred into WHC for a diagnostic follow-up up if they had a prior Pap or co-

test performed by a non-program payment source which yielded an abnormal result, and they meet program eligibility requirements. A clinical pelvic exam must be performed and a copy of the abnormal test results must be included in the medical records before referral to specialist

Cervical Specialist Referral Form

Review PCP section of the form for pelvic exam findings and Pap test results

Only the initial visit requires a referral from the PCP. F, for each additional visit, a new Cervical Specialist Referral Form must be completed

Indicate if the office visit is a repeat pelvic exam or a gynecologic consultation

Indicates the type of recommended/performed diagnostic procedure(s) Indicate the final diagnosis with recommended treatment information and date of services date(s)


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Indicate date of service date(s)

Complete treatment status information

Specialist should discuss exam results with the clientpatient and indicate any concerns in the notes field

Specialist must sign and date the bottom of the page

All original Cervical Specialist Referral Forms must be submitted to the appropriate WHC office within 30 days of date of service

All completed Cervical Specialist Referral Forms must be faxed to WHC within 48 hours of office visit at 775-284-1918 to ensure timely and adequate follow-up

Any test results must be delivered verballyorally or in writing to clientpatients within 10 days of test result receipt

Medicaid Assistance for Treatment of Breast and Cervical Cancer

If a patient is diagnosed with cancer and needs treatment, a WHC Care Coordinator can be reached at 844-469-4930.

Women who apply for Breast and Cervical Cancer Medicaid must meet the following requirements:

At or below 250% of Federal Poverty Level (FPL)

Woman between the age of 21 to 64 years old

Nevada resident

Must be uninsured or underinsured o A woman is considered underinsured when she:

Is in a period of exclusion (such as pre-existing condition exclusion or an HMO affiliation period)

Is not actually covered for treatment of breast or cervical cancer

Has contract healthcare coverage through Indian Health Services or Tribal Clinics

Not eligible under any other Medicaid eligibility group

WHC care coordinators complete and submit Referral Form 2591-EM to the Division of Welfare and Supportive Services for approval. The following documentation must also be submitted:

o Proof of age, income, Nevada residency o Proof of U.S. Citizenship, U.S. National or Alien Status and

For the management of womaen with abnormal screening results the program follows the American Society for Colposcopy and Cervical Pathology (ASCCP) recommendations. Please follow the link for recommendations: http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx



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Eligibility begins the date on which the Care Coordinator determines the woman meets the above eligibility requirements and ends if the woman does not file an application for assistance by the last day of the month following the month during which eligibility was determined. Regular eligibility begins the first day of the first eligible month.

If a woman is diagnosed with cancer through the WHC and is eligible for Medicaid, the services rendered through WHC that lead to diagnosis will need to be billed to Medicaid. Claims will be denied by WHC.

For more information regarding Women’s Health Connection & Medicaid Treatment for Breast & Cervical Cancer please refer to the resource section



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Case Management Services

The WHC provides case management services to ensure that clients receive timely and appropriate screening and diagnostic services and if necessary, treatment services. Staff will explain the importance of follow-up services, and assist with scheduling appointments. Case management services will also assess the client for barriers that could possibly hinder the client to keep follow-up appointments and take action on recommendations. Case management services conclude when a client is determined to have a final diagnosis not requiring treatment or when a client initiates treatment, refuses treatment, or is no longer eligible for WHC.

Responsibilities of Case Management

WHC Care Coordinators conduct an assessment with the client to ensure that the client receives the appropriate services in a timely manner

Coordinate the client’s care with provider(s)

Review clinical records for appropriateness of recommended care




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Ensure recommended diagnostic procedures are completed within time frames

Maintain timely contact with client and documenting all contacts using a tracking system

Assess client for barriers and provide assistance (Transportation, work schedule, etc.)

If diagnosed with cancer, assist client with Medicaid application and track Medicaid approval, and or refer to other treatment resources

Complete Cancer Registry Information section for those clients diagnosed with cancer

Ensure National Breast and Cervical Cancer Early Detection

Medicaid Assistance for Treatment of Breast and Cervical

When a client is diagnosed with breast cancer or a pre-cancerous condition through the Women’s Health

Women who apply for Breast and Cervical Cancer Medicaid must meet the following requirements:

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Must be under age 65

o Must be uninsured or underinsured

o A woman is considered underinsured when she:

o Is in a period of exclusion (such as pre-existing condition exclusion or an HMO affiliation

o Is not actually covered for treatment of breast or cervical cancer

o Has contract healthcare coverage through Indian Health Services or Tribal Clinics

Not eligible under any other Medicaid eligibility group

Must have been enrolled and active by Women’s Health Connection program.screened for breast

o A woman is considered to have been screened if she has received a clinical breast exam, screening mammogram or Pap test or she has received a diagnosis of breast or cervical cancer or of a pre-cancerous condition of the cervix as the result of the screening under the CDC program.

Found to need treatment for breast or cervical cancer or for pre-cancerous condition of the cervix

o A woman is considered to need treatment if, in the opinion of the treating health professional, the diagnostic evaluation following the clinical screening indicates the woman is in need of treatment services. Services include the diagnostic services necessary to determine the extent and proper course of treatment, as well as treatment itself.

o WHC care coordinators complete and submit Referral Form 2591-EM to the Division of Welfare and Supportive Services for approval. The following documentation must also be submitted:

Proof of age, income, Nevada residency o

o Proof of U.S. Citizenship, U.S. National or Alien Status and

o Proof of Nevada residency

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Presumptive eligibility begins the date on which the Care Coordinator determines the woman meets the above eligibility requirements and ends if the woman does not file an application for assistance by the last day of the month following the month during which presumptive eligibility was determined. Regular eligibility begins the first day of the first eligible month.

If a woman is diagnosed with cancer through the WHC and is eligible for Medicaid, the services rendered through WHC that lead to diagnosis will need to be billed to Medicaid. Claims will be denied by WHC.

Reimbursement and Billing The Women’s Health Connection ProgramWHC reimburses at Nevada Medicare allowable rates. A list of allowable CPT codes and reimbursement rates may be found in attachment.

Billing and claims for services

All billing claim forms for services provided to eligible clientpatients must be received at the appropriate WHC office within 30 days of the date of service

Reno Office 4001 South Virginia Street, Suite F Reno, NV 89502 Phone 844-469-4930 Fax 775-284-1918

Do not mail your claim to the Division of Public and Behavioral Health WHC state office in Carson City

Claims will only be paid if the appropriate medical reports and/or exam forms are submitted with the billing claim. Appropriate medical reports and/or exam forms are described below

If a woman is diagnosed with cancer through the WHC and is eligible for Medicaid, the services rendered through WHC that lead to diagnosis will need to be billed to Medicaid. Claims will be denied by WHC

Incomplete claims will be returned to providers with a request for additional information. All corrected claims must be re-submitted within 30 days from denial date.

Providers agree to accept the payable amount as payment in full. If the provider disagrees with the payable amount the provider has 30 days from the date the check was issued to dispute any payable amounts.Please see the Denial Code Attachment for a comprehensive list of denial reasons.

“WHC Enrolled” box must be checked in order for WHC to pay.




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Fiscal Year 2019 runs from 06/30/2018 to 06/29/2019

All Fee for Service CPT Codes run from 06/30/20187 to 06/29/20198 *New CMS CPT Codes that go into effect 1/1/198 will not be honored until 6/29/198

All Fee for Service CPT Codes run from 06/30/2017 to 06/29/2018

Reimbursement for Breast and Cervical Screening Services by PCP

PLEASE NOTE: WHC must have the original completed enrollment documents for the client, or payment for any screening/diagnostic services will be denied.



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Submit the following original paperwork to the appropriate WHC office:.

Original WHCPresumptive Eligibility Enrollment Form – completed and signed

Annual Screening Visit Form – completed and signed Billing Claim Form with WHC covered CPT codes

Reimbursement for Imaging Facilities Before billing for services, you must ensure that the clientpatient has a proper referral form (Mammography and Ultrasound Referral Form) from a contracted PCP. This form must be signed and dated by the clinician. Submit the following original paperwork to the appropriate WHC office:.

Imaging report Billing Claim Form with WHC covered CPT codes

Reimbursement for Breast Specialists Before billing for services, you must ensure that the clientpatient has a Breast Specialist Referral Form from a contracted PCP and the top portion of the form is completed. The form must be completed, signed and dated by specialist. Submit the following original paperwork to the appropriate WHC office:.

Breast Specialist Referral Form

Any documentation pertaining to the diagnostic procedure performed

Pathology results

Billing Claim Form with WHC covered CPT codes

Reimbursement for Cervical Specialists Before billing for services, you must ensure that the clientpatient has a Cervical Specialist Referral Form from a contracted PCP and the top portion of the form is completed. The form must be completed, signed and dated by specialist. Submit the following original paperwork to the appropriate WHC office:.

Cervical Specialist Referral Form

Any documentation pertaining to the diagnostic procedure performed

Pathology results Billing Claim Form with WHC covered CPT codes

Reimbursement for Laboratory Facilities (Pap tests, HPV test, Pathology reports) Submit the following original paperwork to the appropriate WHC office:.

Pap test or pathology result Billing Claim Form with WHC covered CPT codes

Reimbursement for Anesthesia Submit the following original paperwork to the appropriate WHC office:.



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Reimbursement for Ambulatory Surgery Centers Submit the following original paperwork to the appropriate WHC office:

Billing Claim Form with WHC covered CPT codes Submit the following original paperwork to the appropriate WHC office.


Submit the following original paperwork to the appropriate WHC office.



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Las Vegas Office 3085 E. Flaming75 E. Flamingo

Rd., Suite A118 Las Vegas, NV 89121

Phone: (844) 469-4930 Fax: (775) 284-19181918

WHC Directory

If you have questions or concerns about how WHC is working with your organization, please do not hesitate to call WHC program staff. Our goal is to make sure that WHC works the best it possibly can for providers and clientpatients. And as a part of our Quality Management Program, both providers and clientpatients may be asked to participate in a satisfaction survey.

Access to Healthcare Women’s Health Connection Staff

Reno Corporate Office 4001 South Virginia Street, Suite F

Reno, NV 89502 Phone 844-469-4930

Fax 775-284-1918

Sherri Rice Chief Executive Officer Phone: 775-284-9079 Email: [email protected]

Mike O’Carroll Chief Financial Officer Phone: 775-284-1891 Email: [email protected]

Sherri Rice Chief Executive Officer Phone: 775-284-9079 Email: [email protected]

Jamie Rodriguez WHC Manager Phone: 844-469-4930, ext. 210 Fax: 775-284-1918 Email: [email protected]

Mike O’Carroll Chief Financial Officer Phone: 775-284-1891 Email: [email protected]

Ivy Azamar WHC Care Coordinator Phone: 844-469-4930, ext. 212 Fax: 775-284-1918 Email: [email protected]

Erla Orozco Program Director Phone: 844-469-4930ext. 231 Fax: 775-284-1918 Email: [email protected]

Sandra Rodriguez WHC Care Coordinator Phone: 844-469-4930, ext. 297 Fax: 775-284-1918 Email: [email protected]

Denise Savage WHC Claims Processor Phone: 844-469-4930 ext. 267 Fax: 775-284-1918 Email: [email protected]

Yesenia Pacheco WHC Care Coordinator Phone: 844-469-4930 ext. 399 Fax: 775-284-1918 Email: [email protected]

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mailto:[email protected]









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Dena Miguel Program Director Phone: 775-284-8989 ext. 231 Fax: 775-284-1918 Email: [email protected]

Griselda Segura WHC Supervisor Phone: 775-284-8989, ext. 210 Fax: 775-284-1918 Email: [email protected]

Angelica Willis WHC Care Coordinator Phone: 775-284-8989, ext. 297

Fax: 775-284-1918 Email:

Krystal Trigueros WHC Care Coordinator Phone: 775-284-8989, ext. 212 Fax: 775-284-1918 Email: [email protected]

Denise Savage WHC Claims Processor Phone: 775-284-8989 ext. 267 Fax: 775-284-1918 Email: [email protected]

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Melissa Camargo

WHC Care Coordination

Phone: 844-469-4930 ext. 416 Fax: 775-284-1918 Email: [email protected]

Maria Ramirez WHC Data Entry Operator Phone: 844-469-4930 Fax: 775-284-1918 Email: [email protected]





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Las Vegas Office 3075 E. Flamingo Rd, SuiteMariela Moreno 118 WHC Care Coordinator Phone: 702-489-34844-469-493000, ext. 407Las Vegas, NV 89121 Phone 844-469-4930 Fax 775-284-1918

Fax: 775-284-1918 Email: [email protected] [email protected] AHN Helpline: [email protected]

WHC Care Coordinator Phone: 702-489-3400, ext. 407 Fax: 775-284-1918

Email: WHC Care Coordinator Phone: 702-489-3400, ext. 407 Fax: 775-284-1918 Email: [email protected]

AHN Helpline: 1-844-469-493477-385-2345

www.accesstohealthcare.org

Care Coordination Line: 1-844-469-4930

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State of Nevada Women’s Health Connection Staff

Nevada Division of Public and Behavioral Health

Chronic Disease Prevention and Health Promotion Section Women’s Health Connection

4150 Technology Way. Suite 210, Carson City, NV 89706

http://dpbh.nv.gov/ http://dpbh.nv.gov/Programs/WHC/Women_s_Health_Connection_-

_Home/http://dpbh.nv.gov/Programs/WHC/Women_s_Health_Connection_-_Home/http://dpbh.nv.gov/Programs/WHC/Women_s_Health_Connection_-_Home/

Rani ReedLeah Thompson, MPH Population Health & Community Services Manager Population Health Services Manager Phone: 775-687-75814-4092 Fax: 775-684-4245 Email: [email protected] [email protected]

Kellie Ducker WHC Program Coordinator Phone: 775-684-2200 Fax: 775-684-42455 Email: [email protected] Madera Provider & Compliance Training Coordinator Phone: 775-684-4241 Fax: 775-684-4245 Email: [email protected]

Shawna Pascual Tom Weber, MPHProvider Compliance & Training Coordinator Kellie Ducker Health WHC Resource Analyst IIProgram Coordinator Phone: 775-684-4241 Fax: 775-684-4241

Email: [email protected] TBD

Fax: 775-684-4245

Tom Weber, MPH Evaluator and Data Analyst Phone: 775-684-5834 Fax: 775-684-4245

Email: [email protected]

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AHN Helpline: 1-844-469-4934

www.accesstohealthcare.org

Care Coordination Line: 1-844-469-4930

http://dpbh.nv.gov/

http://dpbh.nv.gov/Programs/WHC/Women_s_Health_Connection_-_Home/








http://www.accesstohealthcare.org/


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Email:

Provider Resources The NBCCEDP follows screening recommendations from the United States Prevention Services Task Force (USPSTF). For more information on USPSTF recommendations, please refer to their web-site at:

Breast Cancer Screening http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

Cervical Cancer Screening http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

Nevada Cancer Coalition, Women’s Health Connection & Medicaid Treatment for Breast and Cervical Cancer http://www.nevadacancercoalition.org/whc-medicaid

Cancer Registry http://www.leg.state.nv.us/NRS/NRS-457.html

Who must report to the cancer registry? A health care provider that diagnoses or provides treatment for cancer or other neoplasm. Facilities, medical laboratory, or hospitals that provides screening, diagnostic or therapeutic services to

patients with respect to cancer or other neoplasm. For the management of women with abnormal screening results the program follows the American Society for Colposcopy and Cervical Pathology (ASCCP) recommendations. Please follow the link for

recommendations: http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx


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http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

http://www.nevadacancercoalition.org/whc-medicaid



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Provider Resources The NBCCEDP follows screening recommendations from the United States Prevention Services Task Force

(USPSTF). For more information on USPSTF recommendations, please refer to their web-site at:

Breast Cancer Screening

http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

Cervical Cancer Screening

http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

For the management of women with abnormal screening results the program follows the American Society for

Colposcopy and Cervical Pathology (ASCCP) recommendations. Please follow the link for recommendations:


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Commented [MDM22]: Yes.

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Documents

Women's Health Connection Policy and Procedure Manual