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Scope of Benefits
Cancer Detection Programs: Every Woman Counts (CDP: EWC) is a breast and cervical cancer screening program with benefits reimbursable to all enrolled CDS providers. Case management reimbursement will be offered only to Primary Care Providers (PCPs) when they perform case management services and submit recipient information using the online Recipient Information form and the Breast and Cervical Screen and Follow-Up forms. Case management fees are reimbursable at completion of the data submission and paid only once per woman (per year), whether one screen is needed to complete a normal screening event, or multiple screens are needed for an abnormal workup. More data may be required even after billing for case management. A complete review of these forms will be covered later in this user guide. For a complete list of covered services, please refer to the Cancer Detection Programs: Every Woman Counts section (can detect) of the Medi-Cal manual. This list includes the case management reimbursement code.
Provider Participation
Primary Care Providers
Primary Care Providers (PCPs) are providers who are enrolled through one of the Regional Contractors and have a Provider Enrollment Agreement (PEA) on file with CDS. Some PCPs only enroll for Breast Cancer Screening services, while other enrolled PCPs conduct Breast and Cervical Cancer Screening services. PCPs perform clinical breast exams (CBE) and/or pelvic exams/Pap tests, and coordinate recipients’ care. PCPs are the screening entry point for recipients and are the only providers who can enroll recipients through the Recipient Information online forms and complete and submit the Breast and/or Cervical Cancer Screen and Follow-Up forms. Each PCP must complete a Medi-Cal Point of Service (POS) Network/Internet Agreement and have Internet access to participate in this program. Reporting the final outcome for each recipient of the screening and diagnostic service provided is very important for future program funding.
Referral Providers
Referral providers are any providers to whom PCPs refer patients, for example, radiologists, surgeons, anesthesiologists and pathologists. PCPs can refer recipients to any appropriate
Medi-Cal provider in good standing. PCPs are required to inform the referral providers of the billing requirements, covered services, recipient’s eligibility status, and the 14-digit recipient identification (ID) number. PCPs remain responsible for ensuring that clinical standards of the program are met. PCPs are responsible for obtaining and submitting data (e.g., diagnostic procedures, final diagnosis, staging and treatment status) from the referral provider.
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