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

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).
• 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