Program Manual

Policies and Procedures for the B&C Program

Utah Breast & Cervical Cancer Screening Program Manual for Partners

Introduction

The Utah Breast and Cervical Cancer Screening Program (B&C) serves women who qualify by providing breast and cervical cancer screenings. The B&C Program is a payer of eligible services offered through the program.

This Program Manual provides standardized guidelines to assist providers in understanding the requirements given to B&C as set forth under National Breast and Cervical Cancer Early Detection Program (NBCCEDP) guidelines and to assist B&C in meeting them.

This is a living document that will be updated as needed.

Partnering with the Utah Breast & Cervical Cancer Program

Thank you for participating in the B&C Program. To ensure seamless care and program compliance, participating partners are expected to adhere to the following guidelines:

Administrative & Program Requirements

Sign the Partnership Agreement: Formalize the partnership before rendering services
Accept the fee schedule: Reimbursements are issued using the current NBCCEDP-approved CPT codes.
Submit required paperwork: Deliver all necessary documentation to the B&C Program according to manual guidelines.
Designate a point of contact: Assign a specific staff member or contact to coordinate directly with B&C staff.
Attend program trainings: Participate in all meetings and trainings provided by the B&C Program.

Clinical & Client Care Expectations:

Notify clients of results: Directly inform each client of any abnormal breast and/or cervical screening results.
Manage follow-up & treatment: Make medical decisions and notify B&C regarding client follow-up and treatment recommendations based on results.
Use contracted providers only: Refer B&C clients exclusively to B&C contracted providers for outside care. A list of contracted providers will be shared during training and by reaching out to the program care coordinators.

B&C Eligibility Summary

Eligibility is valid for 12 months. Clients may re-enroll annually if they continue to meet all criteria.

To enroll in the B&C program, clients must meet all the following:

Clinical/Age Requirements:

Cervical Cancer Screening: Ages 21 to 64.
Breast Cancer Screening: Ages 40 and older.
Ages 21–39: Only if symptomatic or high-risk requiring a Clinical Breast Exam (CBE) and/or diagnostic services.

Financial & Insurance Status:

Income at or below 250% of the Federal Poverty Level.
Uninsured or underinsured (Note: B&C acts as the payer of last resort).

Residency:

Utah resident OR resident of a Utah border town with limited screening access (e.g., Mesquite, NV; Colorado City, AZ).
Seasonal workers are eligible if they will reside in the area for at least 3 months.

Exclusions

The B&C program cannot provide services to:

Male clients
Individuals covered by Medicare Part B
Pregnant or breastfeeding clients
Individuals exceeding the income threshold

Clients must have a gross annual income (before taxes and deductions) at or below 250% of the Federal Poverty Level (FPL). Income must be self-reported at registration and verified according to clinic policy.

Defining Household Size

Use these rules to determine the correct household number to check against the FPL chart:

Who to Count: Include the client, their spouse, and any of their children living in the home up until the month the child turns 19.
Temporary Absences (Still Counted):
- Spouse away for work: Count the spouse as part of the household size (and include their income).
- Child < 19 away at college: If a child under 19 lives away for school or other reasons but is still supported by the household, count them in the household size.

What Counts as Income?

Income must include all sources of gross annual income. However, specific types of assistance and household situations are treated differently:

Income Source / Scenario	Countable?	Rule / How to Handle
Gross Annual Income	YES	Use income before any taxes or deductions are taken out.
Alimony	YES	Must be included in the total income calculation.
Spouse Away for Work	YES	Their income must be included (treated as a temporary absence).
Child Support	NO	Do not count toward the client's income.
Food Stamps (SNAP)	NO	Do not count toward the client's income.
Reported "Zero Income"	DEPENDS	Ask the client how they meet living expenses. • If they live with someone who pays all expenses directly, count it as $0 income. • Exception: If someone gives them direct cash that the client controls, that cash is countable.

B&C reimburses clinics for only one clinical visit per eligible patient per year.

Clinics are strongly advised to schedule routine breast and cervical cancer screenings during the same visit. Consolidating appointments removes a major transportation, childcare, and scheduling barrier for low-income clients, ensuring higher compliance.

Covered Services

The following services are fully eligible for coverage under the B&C program:

Routine Clinical Visit: May include a Clinical Breast Exam (CBE) and/or a Pap/HPV test. The B&C Program can pay for a pap test alone every 3 years or co-testing/primary HPV testing every 5 years.
Routine Screenings: Screening mammograms
Advanced Breast Diagnostics:
- Diagnostic mammograms and ultrasounds
- Breast biopsies and fine-needle cyst aspirations
- Surgical consultations
- High-Risk Screening: Breast MRIs are covered for high-risk women, but pre-authorization through B&C is strictly required.
Advanced Cervical Diagnostics: Colposcopies
Treatment Navigation: Referrals to Medicaid and/or other financial assistance programs for breast and cervical cancer treatment.

B&C Non-Covered Services

🛑 Core Policy Rule: The B&C program is strictly a screening and diagnostic program. It does not fund general wellness, family planning, or cancer treatment.

The following services are NOT covered by the B&C Program:

1. General Reproductive & Preventative Health

Testing for Sexually Transmitted Infections (STIs)
HPV vaccinations
Family planning screenings, including IUD placement or removal
Routine cervical cancer screenings for patients who have had a total hysterectomy for non-cervical cancer reasons
- Exception: Call the B&C program office directly to request a case exception if clinically indicated

2. Breast Cancer Treatment & Management

Once a diagnosis moves past screening/biopsy into active treatment, B&C coverage ends. Non-covered services include:

Oncology consults and management
Chemotherapy and/or radiation
Surgical interventions (Mastectomies, lumpectomies, or breast reconstruction)

3. Cervical Cancer Treatment & Advanced Interventions

B&C covers the initial screening and colposcopy, but does not cover subsequent treatment for abnormal results, including:

Oncology, chemotherapy, and radiation
LEEP procedures (Loop Electrosurgical Excision Procedure)
Cone biopsies and therapeutic hysterectomies
Treatment for localized infections

Clients should always be enrolled in the B&C program prior to receiving any services.

Client Enrollment Options

To initiate enrollment, the client must complete one of the following actions:

Apply Online: Complete and submit the online program application.
Apply by Phone: Call the central enrollment line at 1-800-717-1811.

Clinic Document Delivery

Once the client's enrollment is complete and their appointment is scheduled, the B&C program will automatically send two critical documents to the clinic via secure email or fax:

Clinic Eligibility Form: Details the exact screening and diagnostic services this specific client is approved to receive.
Mammogram Payment Voucher: The billing authorization required by the screening facility.

The "Cross-Out" Correction Rule

Before routing paperwork to a screening facility or returning it to the B&C program office, clinic staff must audit the forms for clerical errors.

1. Audit the forms: Review immediately upon receipt. Check the spelling of the client's name, Date of Birth (DOB), and mailing address against your clinic's internal records.

2. Manually correct errors: Do not use white-out or erase. Draw a single line to cross out the incorrect data and clearly write the correct information directly on the form.

3. Route the corrected paperwork: Final step. Send the finalized, corrected documents to the screening facility and back to the B&C program office.

📅 Post-Visit Reporting Deadlines

⏱️ Within 72 Business Hours of the Visit :

Submit the following documents via fax (801-237-0775) or email (uccpmedicalrecords@utah.gov):

Completed Clinic Eligibility Form
Completed Mammogram Payment Voucher & Order
- Note: The order and voucher must also be faxed directly to the imaging facility.
- ⚠️ Crucial Window: Vouchers expire exactly 60 days from the date of the clinic exam.

⏱️ Within 2 Weeks of the Visit

Submit all Pap results and follow-up recommendations via the same fax or email listed above.

Managing Abnormal Results

⚠️ Provider Responsibility: B&C does not make medical decisions for follow-up or treatment. The referring provider is solely responsible for delivering timely follow-up for diagnostic and treatment services.

🎀 Breast Abnormalities Protocol

Patient Notification: Notify the client of any abnormal findings or a final cancer diagnosis immediately.
Order Routing: Fax or email additional diagnostic imaging orders to B&C and your contracted imaging facility.
- B&C Action: B&C will issue new vouchers for covered diagnostic mammograms, ultrasounds, biopsies, and surgical consultations.
Outcome Tracking: Inform B&C of the final diagnostic test or treatment outcome within 2 weeks of the scheduled follow-up appointment.

⏳ Special Rule: Clients Needing a 6-Month Follow-Up

1 Month Prior to Due Date: Fax or email the recommended imaging order to B&C and the imaging facility.
Client Action: Actively encourage the client to call and re-enroll for B&C services so their coverage remains active.

🧬 Cervical Abnormalities Protocol

Patient & B&C Notification: Notify the client of abnormal findings and fax/email the follow-up recommendations to B&C.
Colposcopy Scheduling: If a colposcopy is required, schedule the client directly with a B&C-contracted provider.
Care Coordination: Send the contracted provider's name and the scheduled appointment date to B&C.
- B&C will generate a cervical payment voucher and fax it directly to the receiving provider.
- Notify the Client of a Cancer Diagnosis: Deliver this diagnosis as soon as results are confirmed. The provider is entirely responsible for breaking this news sensitively and outlining the next immediate steps.
- Report Outcomes to B&C (Within 2 Weeks): Inform the B&C program of the patient's diagnostic results or final treatment plan within 14 days of their scheduled follow-up appointment. This keeps their file compliant so treatment navigation can begin.

Once the client is seen, completed documents should be sent by fax (801-237-0775) or email ([email protected]) to B&C:

Completed Clinic Eligibility Form
Completed Mammogram Payment Voucher and order. The order and payment voucher should also be faxed to the imaging facility
Pap results

Abnormal Results

B&C does not make medical decisions for follow-up or treatment. The primary provider is responsible for delivering appropriate and timely follow-up for diagnostic and treatment services.

Breast

Notify clients of any normal and/or abnormal findings
Fax or email additional imaging orders to B&C and contracting imaging facilities
B&C will provide additional vouchers for diagnostic mammograms, ultrasounds, biopsies, and surgical consultations
Inform B&C on the outcome of the patient's diagnostic tests and/or treatment within 14 days of scheduled follow-up appointments
Notify clients of cancer diagnosis

Clients needing 6 month follow-up

Fax or email recommended imaging order to B&C and imaging facility one month prior to being due

Cervical

Notify clients of normal and/or abnormal findings
Fax or email follow-up recommendations to B&C
If a colposcopy is recommended/needed, schedule the client with a contracted OB/GYN provider and provide B&C with the provider's name and date of appointment
B&C will provide a cervical payment voucher and fax to the OB/GYN provider
Inform B&C on the outcome of the patient’s diagnostic tests and/or treatment within 14 days of scheduled follow-up appointments
Notify clients of cancer diagnosis

Workflow for Abnormal Screening Results

Diagnostic Obligation: If a B&C client receives an abnormal or suspicious result, appropriate diagnostic follow-up procedures must be completed to establish a final diagnosis.
B&C Program Coverage: All approved diagnostic follow-up services required to reach that final diagnosis is fully covered and paid for by the B&C Program.
Treatment Limitations: The B&C Program is strictly a screening and diagnostic payer—it does not fund cancer treatment.
Medicaid Program: Patients with a confirmed malignancy must be fast-tracked and referred for treatment. Staff should coordinate a referral to the Utah Medicaid Treatment Act Program to secure comprehensive treatment coverage based on state criteria.

Clinical Timeliness

To ensure high-quality patient care and reduce diagnostic anxiety, the Utah B&C Program enforces a 60-day maximum window for both the diagnostic and treatment phases.

A. Screening-to-Diagnosis Interval

The Metric: The interval between an abnormal or suspicious breast or cervical screening result and the final, definitive diagnosis must be no more than 60 days.
Clinical Obligation: Providers must expedite diagnostic appointments, biopsies, and imaging to ensure patients do not experience a gap in care.

B. Diagnosis-to-Treatment Interval

The Metric: The interval between a confirmed diagnosis of invasive breast or cervical cancer and the formal initiation of cancer treatment must be no more than 60 days.
Clinical Obligation: Case managers and clinicians should prioritize immediate referrals to the state Medicaid Treatment Act Program (or alternative treatment pipelines) to avoid dangerous delays in oncology care.

Clinical Timelines and Patient Navigation Guidelines

To ensure the highest standard of patient care and significantly reduce diagnostic anxiety for our clients, the Utah Breast and Cervical (B&C) Cancer Screening Program enforces strict timing benchmarks for all contracted facilities. All clients must complete their care cycle within a 60-day maximum window from initial contact to final resolution.

The following guidelines outline the expected turnaround times for scheduling, diagnostic follow-ups, and mandatory reporting based on clinical findings. Facilities are expected to adhere to these benchmarks to expedite care, streamline coordination, and ensure seamless communication with the B&C Care Coordinator.

Utah B&C Program: Breast Health Timelines

Scenario / Result	Target Timeline
Maximum Window (All Clients)	Within 60 days maximum
Screening Mammogram	Within 4 weeks of voucher receipt
Diagnostic Mammogram	Within 2 weeks of voucher receipt
Breast Biopsy Needed	As soon as possible
BI-RADS 0 (Incomplete / Needs Additional Imaging)	Within 72 hours
BI-RADS 4 or 5 (Suspicious / Highly Suggestive of Malignancy)	Within 24 business hours
Reporting Results to B&C Care Coordinator	Within 3 business days

1. Reimbursement Rates & "Payor of Last Resort" Rule

The Utah B&C Program reimburses strictly based on current CMS Medicare Rates. Because National Breast and Cervical Cancer Early Detection Program (NBCCEDP) funds may only be used after all other coverage options have been exhausted, the B&C Program acts as the "payor of last resort."

Coordination of Benefits: Prior to billing B&C, you must bill the patient’s primary insurance (including state compensation programs, private policies, or prepaid health entities), if applicable. Once the primary insurer pays, submit the Explanation of Benefits (EOB) to B&C. The program will reimburse the difference up to the allowed rate.
The Tribal Exception: This rule does not apply to clinics or offices operated by the Indian Health Service (IHS) or individual American Indian tribes. For women with alternative resources, the IHS remains the payor of last resort.

2. Claims Submission & Deadlines

Standard Formatting: All claims must be submitted using industry-standard forms, such as the CMS-1500 (1500 Claim Form). Clinics who do not use form CMS-1500 must use Attachment A – B&C Reimbursement Form.
Prior Authorization: B&C will not issue payment prior to receiving a valid claim and is solely responsible for approved, published CPT codes.
Timelines:
- 60 Days: Best efforts should be made to submit claims within 60 days of the date of service.
- 1 Year (Strict Deadline): Claims submitted more than one year after the date of service are strictly ineligible for payment.

3. Balance Billing Prohibition

Providers must accept the B&C Program's payment as payment in full. In accordance with program regulations, clients cannot be balance-billed for any differences, nor can they be billed for claims that were rendered ineligible due to late submission (past the 1-year mark).

Dense Breast Tissue

Clinics should discuss dense breast tissue with clients according to Federal Law.

Americans with Disabilities Act

B&C requires all clinics to conform to the Americans with Disabilities Act (ADA), which prohibits discrimination against people with disabilities in several areas, including transportation, public accommodations, communications, and access to state and local government programs and services.

Clinic staff are encouraged to complete the training on servicing individuals with disabilities.

Language Interpretation Services

Partners should make best efforts to provide language interpretation services for Patients whose primary language is not English.

High-Risk Criteria for Breast and Cervical Cancer

While partner clinics are welcome to utilize any verified risk assessment tool, the Utah B&C Program aligns with the CDC in classifying the following individuals as High Risk:

Breast Cancer High-Risk Criteria

Patients are considered high risk for breast cancer if they meet any of the following benchmarks:

Genetic Factors: Possession of a known genetic mutation (e.g., BRCA1 or BRCA2).
Family History: Having a first-degree relative (parent, sibling, or child) diagnosed with premenopausal breast cancer or a known genetic mutation.
Medical History: A history of radiation therapy to the chest area before the age of 30 (most commonly administered for Hodgkin’s lymphoma).
Risk Modeling: A calculated lifetime risk of 20% or greater for developing breast cancer, utilizing risk assessment models that heavily weigh family history (such as the Tyrer-Cuzick or Gail models).

Cervical Cancer High-Risk Criteria

Patients are considered at high risk for cervical cancer if they are:

Living with an HIV infection.
Recipients of an organ transplantation.
Otherwise immunocompromised due to an underlying health condition or medical treatment.

HPV Self-Collection Approved

The Utah B&C Program covers self-collection HPV testing for primary cervical cancer screening.

No Coding Changes: Bill using your current, standard CPT codes for HPV testing.
Protocol Reminder: The self-collection sample must be gathered in-office/in-clinic under supervision.
Learn More: Watch "USPSTF Cervical Cancer Guidelines and HPV Self-Collection" for an overview of the guiding clinical framework.

Program Contact Information

Resource	Contact Information
Mailing Address	PO Box 142107 Salt Lake City UT 84114-2107
Street Address	288 N 1460 W Salt Lake City UT 84116
Toll-free phone number	800-717-1811
Fax number	801-237-9030
Email	[email protected]
Billing	Fax: 801-237-0769 Email: [email protected] Cell: 801-793-8774

ATTACHMENT A – B&C REIMBURSEMENT FORM

Clinic LOGO

Breast and Cervical Cancer Program Reimbursement Form for clinics which do not use CMS-1500 or 1450 forms: Please complete for each B&C eligible client and send electronically to secure fax at 801-237-0769 or email to [email protected]

Clinic Name: Billing Contact Name:
Contact Phone Number Contact email:

Client Information:

Name: Date of Birth:
Date of Service: Client Account Number:

Check one below (labs are billed separately)

[ ] Clinical Breast Exam and Cervical Exam (Pap and/or HPV test)

[ ] Cervical Exam only (Pap and/or HPV test))

[ ] Clinical Breast Exam only

[ ] Underinsured client (Local Health Departments Only)

For Cervical labs please send lab invoices separate from clinic invoices to secure fax at 801-237-0769 or [email protected].

Submit one reimbursement form per client within 30 days from date of service to ensure prompt payment. For more information, please refer to the B&C Program Manual located at cancer.utah.gov.