3300, Clinical Policy

Body

Revision 24-2; Effective Sept. 20, 2024

3310 BCCS Grantee Clinical Responsibilities

Revision 25-3; Effective Sept.1, 2025

Grantees must:

  • administer pelvic examinations per Chapter 167A of the Health and Safety Code;
  • accept referrals for Breast and Cervical Cancer Services (BCCS), funds permitting;
  • assess all clients for their need of patient navigation services and provide such services accordingly;
  • help eligible clients apply for Medicaid for Breast and Cervical Cancer (MBCC), including eligible clients diagnosed outside the BCCS program;
  • make a good faith effort to get treatment for clients with a precancerous or cancerous breast or cervical diagnosis who do not meet the eligibility criteria for BCCS cervical dysplasia, MBCC or both;
  • communicate with team members within your organization about program requirements of the BCCS program;
  • provide and document monitoring and oversight of subrecipients and subcontracted services to ensure compliance with BCCS policies and standards;
  • establish policies and procedures to ensure accurate information about BCCS and MBCC is provided when people call about services;
  • train staff annually on these policies and procedures; and
  • ensure callers are connected to staff responsible for scheduling appointments and answering program related questions in a timely manner.

3311 Covered Services

Revision 24-2; Effective Sept. 20, 2024

Breast and Cervical Cancer Services (BCCS) program services include:

  • clinical breast examination;
  • mammogram;
  • pelvic examination and Pap test;
  • diagnostic services;
  • cervical dysplasia management and treatment; and
  • help completing the Medicaid for Breast and Cervical Cancer (MBCC) application.

Detailed information on available BCCS services is in the BCCS Billing Guideline.

Telemedicine

Providers may provide services by telemedicine if appropriate. Providers who provide telemedicine services must follow all rules per the Texas Occupations Code 111.001 and must have written policies and procedures to do so that include:

  • Informed consent;
  • Confidentiality of the client’s clinical information;
  • Ensure appropriate, quality care;
  • Prevent abuse and fraud in the use of telemedicine services;
  • Ensure adequate supervision of health professionals who are not physicians and who provide telemedicine care.
  • Establish the maximum number of health professionals a physician may supervise through telemedicine services.

3320 Client Health Record and Documentation of Client Encounters

Revision 24-2; Effective Sept. 20, 2024

Client Health Records and Documentation

Grantees must make sure a client health record, a medical record, is established for every client who obtains BCCS services.

All client health records must be:

  • complete, legible, written in ink or documented within an Electronic Medical Record (EMR). No erasures or deletions should occur in a health record.
  • accurate documentation of all clinical encounters, including those by phone.
  • signed by the provider who makes the entry, including the provider’s name, title and date for each entry.
    • Note: Electronic signatures are acceptable to document provider review of care. Stamped signatures are not acceptable.
  • readily accessible to assure continuity of care and availability to patients.
  • systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • client identification, personal data and eligibility assessment, including an insurance assessment.
  • preferred language, method of communication or both.
  • client contact information with the best way to reach the client in a way that facilitates continuity of care, assures confidentiality and adheres to Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations.
  • a problem list, updated as needed at each encounter, that indicates significant illnesses and medical conditions.
  • a complete medication list that includes prescription and nonprescription medications and dietary supplements, updated at each encounter.
  • a complete list of all medication allergies, adverse reactions and other allergic reactions displayed in a prominent place and confirmed or updated at each encounter. Properly note if the person has no known allergies.
  • the person’s past medical history that includes all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history.
  • a person’s health risk survey and assessment, which includes:
    • past and current tobacco, alcohol and substance use or misuse.
    • domestic or intimate partner violence, abuse or both. For any positive result, the person must be offered referral to a family violence shelter per Texas Family Code, Chapter 91.
    • occupational and environmental hazard exposure.
    • environmental safety, which can include seat belt use, car seat use and bicycle helmets.
    • nutritional and physical activity assessment.
    • living arrangements updated as appropriate at each encounter.
  • at each encounter, an encounter-relevant history and physical examination pertinent to the person’s reason for presentation.
  • assessment or clinical impression.
  • a plan of care consistent with diagnoses and assessments, which are consistent with clinical findings, including:
    • education,
    • counseling,
    • treatment,
    • special instructions,
    • scheduled visits, and
    • referrals.
  • appropriate laboratory and other diagnostic test orders, results and follow-up as indicated.
  • recommended follow-up care, scheduled return visit dates and follow-up for missed appointments.
  • informed consent or refusal of services, to include at a minimum:
    • general consent for care,
    • informed consent for any surgical or invasive procedures as indicated, and
    • for required or recommended services refused or declined by the person, documentation of the service offered, counseling provided and the person’s decision to decline.
  • client counseling and education with attention to risks identified in the health risk assessment.

Note: The record must be updated at every clinic visit as appropriate. The reason for the visit, assessments made, if any, and the service provided must be documented.

A comprehensive client health record described above does not have to be established for clients referred only for Medicaid for Breast and Cervical Cancer (MBCC) assistance. The BCCS grantee must establish a Patient Navigation Record for these clients.

3321 Counseling and Education

Revision 23-2; Effective Sept. 29, 2023

For every woman who receives breast or cervical cancer screening, or both, or diagnostic services through BCCS, the service provider must effectively communicate and document the following information during the initial visit and update it during follow-up visits, as indicated by the client’s risk assessment:

  • Risk factors for breast and cervical cancer
  • Signs and symptoms of breast and cervical cancer
  • The importance of cancer screening at regular intervals
  • Limitations of screening, including limitations of imaging in women with dense breast tissue
  • Information on human papilloma virus (HPV) and safe sex practices
  • Information on the HPV vaccine
  • An advisory that BCCS services and eligibility may change from year to year
  • Information about tobacco cessation and a quit line referral, if appropriate

Tobacco Use Assessment and Texas Tobacco Quitline Referral

All women receiving BCCS services must be assessed for tobacco use consistently through standardized screening and referral procedures at every encounter. The assessment should be performed by agency staff and documented in the clinical record. Cessation rates improve when healthcare providers spend at least three minutes counseling their patients. Screening, counseling and referral to treatment do not need to be performed by the same healthcare provider.

Women who use any type of tobacco product, including electronic nicotine delivery systems, should be referred to the Texas Tobacco Quitline via one of the following:

The Texas Tobacco Quitline provides confidential, free and convenient cessation services to Texas residents ages 13 and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 1-877-YES-QUIT (1-877-937-7848) or online at YesQuit.org.

3330 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 23-2; Effective Sept. 29, 2023

Follow-up of Breast and Cervical Screening Results

The clinician must notify a woman of findings, reinforce the need for continued routine screening examination and provide the expected interval for her next routine screening examination. Grantees must attempt to remind each woman of her regular screening due date.

Rescreening Eligibility

Rescreening is the process of returning for a breast cancer screening or cervical cancer screening (or both) at a pre-determined interval (as per program guidelines) when no symptoms are present.

Women may return for rescreening if they continue to meet BCCS financial and clinical eligibility requirements. Women with a history of cancer may return for screening when they conclude their cancer treatment if they continue to meet BCCS financial and clinical eligibility requirements.

Exceptions to Rescreening

Grantees are not required to rescreen a client if the grantee has documented that she:

  • cannot be located or has moved from the contractor’s service area;
  • no longer meets the BCCS financial or clinical eligibility;
  • has Medicare Part B or other adequate health insurance which provides coverage for breast and cervical cancer screening and diagnostic testing; or
  • refuses, in writing or verbally, to return for services.

3331 Prescriptive Authority Agreements

Revision 25-3; Effective Sept. 1, 2025

The grantee is responsible for making sure a properly executed prescriptive authority agreement (PAA) is in place for each mid-level provider when an advanced practice registered nurse (APRN) or physician assistant (PA) provide services. The PAA must meet all requirements in Texas Occupations Code, Chapter 157, including the following criteria:

  • be in writing and signed and dated by the parties to the agreement;
  • be reviewed at least annually, including amendments;  
  • be kept on-site where the APRN or PA provides care;  
  • include the name, address and all professional license numbers of all parties to the agreement;
  • state the nature of the practice, practice locations or practice settings;
  • identify the types or categories of drugs or devices that may or may not be prescribed;
  • provide a general plan to address consultation and referral;
  • provide a plan to address client emergencies;
  • describe the general process for communication and sharing information between the physician and the APRN or PA to whom the physician has delegated prescriptive authority about the care and treatment of clients;
  • if alternate physician supervision is used, appoint one or more alternate physicians who may:
    • provide appropriate temporary supervision following the requirements established by the PAA and the requirements of this section; and
    • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section;
  • describe a prescriptive authority quality assurance and improvement plan and specify methods to document the implementation of the plan that includes:
    • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA; and
    • periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or physician assistant.

References

3340 Standing Delegation Orders

Revision 25-3; Effective Sept. 1, 2025

Standing Delegation Orders (SDOs) are written instructions, orders, rules, or procedures designed for a client population with specific diseases, disorders, health problems or sets of symptoms. This type of order provides a general set of conditions and circumstances when action can be instituted before being examined or evaluated by a physician. Clinics must have written SDOs in place as outlined in TAC Title 22, Part 9, Chapter 169, Subchapter A.

Standing delegation orders may permit the administering or providing of the following types of dangerous drugs if specifically ordered by or using a pre-signed prescription from the delegating physician:

  1. oral contraceptives;
  2. diaphragms and contraceptive creams and jellies;
  3. topical anti-infectives for vaginal use;
  4. oral anti-parasitic drugs for treatment of pinworms;
  5. topical anti-parasitic drugs;
  6. antibiotic drugs for treatment of venereal disease; or
  7. immunizations

General standards for standing delegation orders, standing medical orders, and protocols require:

  1. development and approval by the delegating physician or per facility bylaws and policies;
  2. the order or protocol to be in writing and signed by the delegating physician;
  3. a description of the specific instructions, orders, protocols or procedures to be followed,
  4. a notation of the level of supervision required, unless specified by other law;
  5. plans for addressing client emergencies;
  6. annual review signed by the delegating physician; and
  7. maintenance at the facility or practice site.

3341 Breast Clinical Policy

Revision 26-1; Effective Jan. 8, 2026

Breast Cancer Screening Eligibility

Applicants who meet general eligibility requirements and have breasts are eligible for breast cancer screening services. Breast screening refers to procedures that include clinical breast examination (CBE), screening mammogram and MRI for women who present without symptoms suspicious for breast cancer. For breast cancer screening to be most effective, the screening must be conducted at regular intervals.

Risk Screening and Client Counseling

All women should undergo a risk assessment to find out if they are at high risk for breast cancer. Women considered high risk include those who have:

  • a known genetic mutation such as BRCA 1 or 2;
  • first-degree relatives with premenopausal breast cancer or known genetic mutation;
  • a history of radiation treatment to the chest area before they are 30 years old, typically for Hodgkin’s lymphoma;
  • a lifetime risk of 20% or more for development of breast cancer based on risk assessment models largely dependent on family history; or
  • Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Providers can choose the risk assessment method they prefer to find out if a woman is at high risk for breast cancer. Women at high risk should be screened with both an annual mammogram and an annual breast MRI.

All people should be counseled on breast cancer awareness and advised to be familiar with their breasts and to report promptly any changes such as a mass, lump, thickening or nipple discharge.

All people should be counseled on the benefits and risks of mammography. If a person has the option of a 3-D mammogram, they should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision.

Screening Frequency

The following women may receive breast cancer screening services every one to two years based on the woman’s history and clinical presentation:

  • women 40 and older, and
  • high-risk women younger than 40.

Note: Grantees must use the Health History Screen in Med-IT®  to document high-risk assessment.

3342 Components of Breast Cancer Screening

Revision 25-3; Effective Sept. 1, 2025

The grantee must provide a complete breast cancer screening, which includes a mammogram, individualized client education, tobacco use assessment and Quit Line referral, if indicated. A screening may include a clinical breast examination (CBE). The grantee must document the breast cancer screening components in the client’s record and Med-IT®.

A breast health history must be included as part of the breast cancer screening. The health history includes:

  • date and time intervals of previous mammograms;
  • results of previous mammograms;
  • date and results of the last CBE;
  • date and results of any previous breast surgery;
  • date of last menstrual period;
  • medication history, including current or previous use of hormones such as hormone replacement therapy and oral contraceptives;
  • other risk factors for breast cancer such as personal history of breast cancer or family history of first-degree relatives with breast cancer; and
  • description of breast symptoms, if any.

Clinical Breast Examination

A CBE is not a prerequisite for reimbursement for a screening mammogram by the BCCS program. Grantees should document if a CBE is not indicated for Minimum Data Element (MDE) records. CBEs must be performed by a physician, physician assistant, nurse practitioner, certified nurse midwife or additionally a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The specialized RN CBE training must be documented in the personnel record including an educational certificate, a degree, or continuing education credits. Complete documentation of the CBE must be included in the client health record and Med-IT®.

Screening Mammogram Special Circumstances

Additional views, as used with a diagnostic mammogram such as four to six specified diagnostic views, can be used to screen women with the following special circumstances:

  • Cosmetic or reconstructive breast implants
  • A history of breast cancer and lumpectomy (partial mastectomy)

Screening Magnetic Resonance Imaging (MRI)

Breast MRI may be reimbursed by BCCS along with a screening mammogram after program approval. Grantees must request approval using Form 5203, Breast MRI Pre-Authorization Request. Once reviewed by HHSC clinical staff, Form 5203 is returned to the grantee within 10 business days.

Breast MRI can also be reimbursed when used to better assess areas of concern on a mammogram or for evaluation of a client with a history of breast cancer after completing treatment.

MRI Restrictions:

  • Breast MRI must never be performed alone as a breast cancer screening tool.
  • Breast MRI cannot be reimbursed to assess the extent of disease for staging in women already diagnosed with breast cancer.
  • All breast MRI procedures require pre-authorization.
  • MRI procedures must be performed in facilities with dedicated breast MRI equipment able to perform MRI-guided breast biopsies.

Imaging Reports – Screening Mammogram and MRI

Radiology facilities must prepare a written report of the results of each radiologic examination, including screening mammography and MRI. This report must include the following:

  • name of the client and an additional client identifier;
  • name of the physician who interpreted the mammogram; and
  • an overall final assessment of findings using the Breast Imaging Reporting and Data System (BIRADS) classification.

Funding for Screening Mammograms and MRI

Reimbursement for screening mammograms and MRI for high-risk asymptomatic women 40 – 49 must initially be billed using the B codes listed in the BCCS Billing Guideline.

Note: BCCS funds may not be used for breast cancer screening in clients under 40.

3343 Breast Cancer Diagnostic Services

Revision 25-1; Effective Feb. 4, 2025

Breast Cancer Diagnostic Eligibility

Applicants 18 to 64 may be eligible for breast cancer diagnostic services if they have an abnormal breast cancer screening result and meet program eligibility requirements.

Managing Women with Abnormal Breast Cancer Screening Results

The management of women whose mammogram, clinical breast examination (CBE), or both, are abnormal relies on a body of scientific literature that is constantly growing and changing. Providers should follow standards such as the Breast Cancer Screening and Diagnosis - Guidelines Detail and the Clinical Resources.

Reimbursement for Complications of Breast Procedures

Grantees may request reimbursement for treatment costs associated with client complications related to breast biopsy procedures that occur in the immediate post-procedure or post-operative period, excluding inpatient hospital services. Grantees may be reimbursed through a voucher system for approved charges up to $3,000 per occurrence from awarded contract funds. To request reimbursement, grantees must email the Breast and Cervical Diagnostic Procedure Complication Reimbursement Request Form 5205 and supporting documents to BCCS program staff at BCCSprogram@hhs.texas.gov.

Supporting documents include the following:

  • The client’s Med-IT® ID and date of service when treatment procedures were performed on the client in question.
  • A narrative summary detailing the breast biopsy procedure performed and any related complications which have been documented in the Navigation or Cycle Note section of the client’s Med-IT® record.
  • All emergency room, surgical and office progress notes, and similar notes related to complications of the procedure.
  • The procedure notes, operative report or both, and similar documentation for the initial procedure.
  • A completed paper Health Insurance Claim Form (CMS-1500) detailing the procedures for which the grantee is seeking reimbursement.

List all procedures related to the complication even if they are not typically reimbursable under the BCCS Program.

3350 Cervical Clinical Policy

Revision 24-2; Effective Sept. 20, 2024

3351 Cervical Cancer Screening Services

Revision 26-1; Effective Jan. 8, 2026

Applicants who have a cervix and present without symptoms suspicious for cervical cancer are eligible for cervical cancer screening services. Cervical screening refers to procedures that include pelvic exam, Pap test and Human Papilloma Virus (HPV) testing. For cervical cancer screening to be most effective, the screening must be conducted at regular intervals. Outreach efforts should be focused on persons who have never been screened or not been screened for cervical cancer within the past 10 years.

Cervical Cancer Screening Management

Cervical cancer screening is primarily performed with the Pap test and the HPV DNA test. BCCS uses U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.

Clinical and reimbursement guidelines for cervical screening are:

  • 21 – 29: Screen for cervical cancer every three years with cytology alone.
  • 30 – 64: Screen for cervical cancer every three years with cytology alone, or every five years with hrHPV testing alone, or every five years with cotesting.
  • Younger than 21: Not eligible for cervical cancer screening.

Special circumstances may warrant alterations in screening intervals as determined by a clinician. Special circumstances must be documented in the Med-IT® Minimum Data Elements (MDE) Summary of Notes section. This section is under the BCC Data section (BCC – MDE Notes). Special circumstances may include:

  • Clients considered high-risk, for example, HIV positive, immunosuppressed, exposed to diethylstilbestrol (DES) in utero or history of cervical cancer.
  • Clients who had a hysterectomy for cervical intraepithelial neoplasia (CIN) disease. These clients may continue screening for 20 years.
  • Clients who have had cervical cancer. These clients may be screened indefinitely if they are in good health.
  • Clients who have had a hysterectomy for benign disease and the cervix is still present. These people may be eligible for cervical cancer screening services. Funds can be used to pay for an initial exam to determine if the cervix is still present.

3352 Cervical Cancer Diagnostics

Revision 25-1; Effective Sept. 1, 2025

Cervical Cancer Diagnostic Eligibility

Applicants 18-64 years old who meet BCCS general requirements may receive diagnostic services. BCCS funded diagnostics services must be delivered per the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines.

Follow-up for Abnormal Cervical Screening

When the results are abnormal more diagnostic follow-up is required. A normal Pap test does not rule out cancer if a woman has a cervical lesion on pelvic examination. A colposcopy, cervical biopsy or both are allowed if determined appropriate by the clinician after an abnormal pelvic exam.

BCCS grantees must follow the algorithms for the management of the specific type of abnormal result and in consideration of special populations such as pregnant women and clients 20 years and younger or at high-risk. Refer to 3341, Breast Clinical Policy, for more information about risk screening and client counseling.

Diagnostic Procedures

Tests performed to confirm or rule out cancer when screening tests yield abnormal results include colposcopy, cervical biopsy, endocervical curettage (ECC) and diagnostic excisional procedures. A clinical breast exam (CBE) is not required when a client is referred to BCCS after an abnormal pelvic exam or abnormal Pap test. Diagnostic procedures must be performed by qualified clinicians with specialized training such as physicians, physician's assistants, nurse practitioners or certified nurse midwives.

Clinical Utilization Restrictions for Diagnostic Procedures

Diagnostic loop electrosurgical excision procedure (LEEP), conization, laser conization and cold knife conization cannot be performed on the following clients:

  • Any age in the absence of high-grade squamous intraepithelial lesion (HSIL), ASC-H or higher abnormality.
  • Any age with histology cervical intraepithelial neoplasia (CIN) I or lesser abnormality for a duration of less than two years and in the absence of HSIL or atypical glandular cells (AGC) on Pap tests.

Other Restrictions

The BCCS program monitors the use of facility and anesthesia services for cold knife conization and for use with LEEP.

Grantees are encouraged to develop subcontracts with practitioners who have specialized training in the management of cervical disease, including LEEP, as an office-based procedure.

Consultations

Consultations for follow-up of abnormal cervical results must be performed by health care providers with specialized training in the management of cervical disease, including skill performing invasive diagnostic procedures.  

A consultation may be performed only by a health care provider who did not perform the original screening examination. If that health care provider is not a licensed physician, appropriate protocols must be established and documented for that provider. Consultations must involve direct examination of the client and be billed using office visit codes.

Access to Treatment

The following treatment options may be available for eligible clients with a qualifying diagnosis:

  • Cervical dysplasia management and treatment of clients who have a qualifying diagnosis and are not eligible for Medicaid for Breast and Cervical Cancer (MBCC). For a description of qualifying diagnoses, see 3353, Cervical Dysplasia Management and Treatment.
  • MBCC for applicants who have qualifying breast or cervical cancer diagnoses and meet all other MBCC eligibility criteria. Refer to 3354, Medicaid for Breast and Cervical Cancer, and the MBCC Guidelines for Determination of Qualifying Diagnosis for guidance.

Office-based Procedures Performed in an Ambulatory Surgical Center

Special circumstances may arise that necessitate an office-based diagnostic procedure being performed in an ambulatory surgical center. These services require pre-authorization before the client receives services in an ambulatory surgical center or other outpatient facility. Grantees must submit the Office-based Procedures Performed in an Ambulatory Surgical Center Pre-authorization Form 5204, along with all supporting documentation to the BCCS Program staff. Once reviewed by BCCS clinical staff, Form 5204 is returned to the grantee within 10 business days. BCCS will not reimburse for any office-based procedures performed in an ambulatory surgical center are not pre-authorized. Evidence of pre-authorization approval must be made available to BCCS review staff during monitoring on-site visits.

Note: Special circumstances may include clients with a history of cervical cancer, obesity, cervical stenosis, vaginal stenosis or atrophy.

Reimbursement Following Complications of LEEP and LEEP Conization Procedures

Grantees may request reimbursement for treatment costs associated with client complications related to LEEP and conization procedures that occur in the immediate post-procedure or post-operative period, excluding inpatient hospital services. Grantees may be reimbursed through a voucher system for approved charges up to $3,000 per occurrence from awarded contract funds. To request reimbursement, grantees must email the Breast and Cervical Diagnostic Procedure Complication Reimbursement Request Form 5205 and email supporting documents to BCCS program staff.

Supporting documents include:

  • The client’s Med-IT® ID number and date of service when the treatment procedure was performed on the client in question.
  • A narrative summary that details the LEEP or conization procedure performed and related complications which have been documented in the Case Management or Cycle Note section of the client’s Med-IT® record.
  • All emergency room, surgical and office progress notes for the client related to complications of the procedure.
  • The procedure notes and operative report, or both for the initial procedure.
  • A completed Health Insurance Claim Form, CMS-1500, that details the procedures that the grantee seeks reimbursement. List all procedures about the complication even if they are not typically reimbursable under the BCCS program.

3353 Cervical Dysplasia Management and Treatment

Revision 25-3 Effective Feb. 4, 2025

Grantees may receive limited state funding for management and treatment of cervical dysplasia (CD). CD procedures are reimbursed from non-federal funding, as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) prohibits use of The Centers for Disease Control and Prevention (CDC) grant funds for treatment.

Cervical Dysplasia Eligibility

Applicants must meet BCCS general eligibility criteria and have a definitive, biopsy-confirmed diagnosis of one of the following:

  • CIN I, CIN II, CIN II-III; or
  • high-grade dysplasia, which is severe dysplasia, or CIN III or CIS.

Grantees must assess clients with severe dysplasia, CIN III or CIS for MBCC eligibility before using non-federal funding to pay for treatment services.

Components of Cervical Dysplasia Services

Cervical dysplasia management and treatment may include the following services:

  • Follow-up testing and observation without treatment, for example, cytology Pap tests, HPV testing and colposcopy.  
  • Treatment using excision or ablation, for example, cryotherapy and cervical conization.
  • Patient Navigation, refer to 3360, Patient Navigation Services.

Reimbursement for Cervical Dysplasia Management and Treatment Services

Reimbursement for cervical dysplasia services is limited to the codes which begin with CD, FCX and FCD listed separately in the BCCS Billing Guideline. These codes must be billed in the Med-IT® system. Grantees should bill CD services throughout the dysplasia plan of care and return clients to BCCS services once released to routine screening intervals by the provider.

BCCS grantees must submit specimens for program covered laboratory testing to a U.S. Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory and adhere to all quality management requirements for cytology quality assurance.

Office-based Procedures Performed in an Ambulatory Surgical Center

Special circumstances may arise that necessitate an office-based diagnostic procedure being performed in an ambulatory surgical center. These services require pre-authorization before the client receives services in an ambulatory surgical center or other outpatient facility. Grantees must submit the Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Form 5204, along with all supporting documentation to BCCS Program staff. Once reviewed by BCCS clinical staff, Form 5204 is returned to the grantee within 10 business days. BCCS will not reimburse for any office-based procedures performed in an ambulatory surgical center that are not pre-authorized. Evidence of pre-authorization approval must be made available to BCCS review staff during monitoring on-site visits.

Note: A special circumstance may be an abnormal pelvic exam, a client with a history of cervical cancer, obesity, cervical stenosis, vaginal stenosis or atrophy.

3354 Medicaid for Breast and Cervical Cancer

Revision 25-3; Effective Sept.1, 2025

The Texas Health and Human Services Commission (HHSC) administers the Medicaid for Breast and Cervical Cancer (MBCC) Program. MBCC is a special Medicaid program authorized by federal and state laws to provide access to cancer treatment services through full STAR+PLUS Medicaid benefits to qualified women. Refer to 42 Code of Federal Regulations Section 435.213, Human Resources Code Section 32.024(y) and (y-1) and TAC Title 1, Part 15, Chapter 366, Subchapter D.

Grantees must help women across the state, who are diagnosed with breast or cervical cancer by a BCCS grantee, who self-refer, or are referred by a non-BCCS provider, with completion and submission of the MBCC application. Grantees must determine presumptive eligibility for qualified women, and assess patient navigation per protocols specified in 3360, Patient Navigation Services. Grantees must offer in-person and remote options to help women complete and submit MBCC applications.

MBCC Eligibility

Applicants must meet each of the following criteria:

  • have a biopsy-confirmed qualifying breast or cervical cancer diagnosis;
  • need treatment for  breast or cervical cancer;
  • be at or below 200% of the federal poverty level;
  • be uninsured meaning, she must not otherwise have creditable coverage;
  • be under 65 years old;
  • provide their Social Security number or proof they have applied for one;
  • be a U.S. citizen or eligible immigrant; and
  • be a Texas resident.

Refer to MBCC eligibility guidelines and verification requirements in Part X- Medicaid for Breast and Cervical Cancer of the Texas Works Handbook.

Presumptive Eligibility

Presumptive eligibility is a Medicaid option that allows states to enroll women in Medicaid for a limited period before a full citizenship or legal immigrant eligibility determination is complete. Presumptive eligibility facilitates the prompt enrollment and immediate access to services for women who need treatment for breast or cervical cancer. The earliest date presumptive eligibility may begin is the day after the client received a biopsy-confirmed qualifying diagnosis.

Coverage

The earliest date a woman may be enrolled in full Medicaid coverage through MBCC is the day after a biopsy-confirmed qualifying diagnosis. Coverage may continue through the duration of her cancer treatment. MBCC services include the full range of Medicaid benefits and the treatment of breast or cervical cancer. If a client has a question about her Medicaid benefits or wants to locate a Medicaid provider in their area, she can call the TMHP Medicaid Client Help Line at 800-335-8957.

A client can continue to receive MBCC benefits if she meets the eligibility criteria and provides proof from her treating physician that she is receiving active treatment for breast or cervical cancer. The client must return Form H1551, Treatment Verification, and Form H2340, Medicaid for Breast and Cervical Cancer Renewal, to HHSC Centralized Benefit Services (CBS) before the end of the 12-month coverage renewal period.

If the client’s cancer is in remission and the physician determines the client requires only routine health screenings such as annual breast examinations, mammograms or Pap tests as recommended by the American Cancer Society and the U.S. Preventative Services Task Force, the client is not considered to be receiving treatment and MBCC coverage would not be renewed. If a client is later diagnosed with a new breast or cervical cancer, recurrence of breast or cervical cancer, or metastasis related to the primary qualifying diagnosis, she may reapply for MBCC.

BCCS Grantee Responsibilities

BCCS grantees are responsible for determining presumptive eligibility for qualified women and assessing patient navigation needs.

Initial BCCS grantee and subrecipient responsibilities include:

  • collection and review of documents for eligible income, age, insurance, citizenship, and biopsy-confirmed qualifying diagnosis.
  • help completing Forms 1065 and H1034;
  • completion of Med-IT® data entry and billing before submitting the completed MBCC application to BCCS, which includes the Final Diagnosis and Treatment screen in Med-IT for clients diagnosed with BCCS funds.

BCCS grantees must submit the MBCC application and other required documents no later than two working days from the date presumptive eligibility determination is made. For MBCC application instructions, refer to Appendix I, Medicaid for Breast and Cervical Cancer (MBCC) Application Checklist. For determining a qualifying diagnosis, refer to Appendix II, Medicaid for Breast and Cervical Cancer (MBCC) Guidelines.

BCCS State Office Responsibilities

BCCS program staff are responsible for reviewing the client’s application, required clinical documents and other required documentation. Staff submit the information to HHSC Centralized Benefit Services (CBS) within five business days of receipt of the complete application package.

Note: Once submitted for consideration to HHSC CBS, BCCS staff cannot review the application status. Staff do not help with or collect documents for pended MBCC applications.

HHSC MBCC Eligibility Staff Responsibilities

HHSC CBS staff verify receipt of the Form H1034 application within 48 hours and process the application within two business days of receipt. If more information is required, clients are placed on MBCC presumptive status and allowed 10 days to provide the required information. Eligibility for all applications is determined within 45 calendar days of receipt of the application packet.

Eligibility Determination Group (EDG) disposition is the result of processing the request for assistance and making an eligibility determination. The Texas Integrated Eligibility Redesign System (TIERS) generates Form TF0001, Notice of Case Action when the EDG is disposed. Form TF0001 is sent the same day eligibility is determined. This notice informs clients of their Medicaid status with an effective date of coverage and notifies the client of their EDG number. Clients may contact 2-1-1 to request the status of their application and Medicaid number.

MBCC inquiries from BCCS grantees on client reinstatements, approvals, denials and final application status should be emailed to Centralized Benefit Services-Medicaid for Breast & Cervical Cancer (CBS MBCC).

Medicaid Reinstatement

A client enrolled in Medicaid under MBCC within the past 12 months, and who is no longer on Medicaid but is still in active treatment or in need of active treatment for the original cancer, may have her MBCC reinstated. Reinstatements are handled directly by HHSC CBS. The BCCS grantee may help the client by:

  • requesting Form H1551 and Form H2340 by calling 2-1-1 or 877-541-7905;
  • helping complete the required documents; and
  • faxing Forms H1551 and H2340 to HHSC CBS.

State-to-State Transfers

State-to-state transfers are handled by HHSC CBS. Form H1034 should not be submitted.

Clients must request an out of state MBCC application,  Form H2340-OS, Medicaid for Breast and Cervical Cancer and Form H1550, Out of State NBCCEDP Verification. These forms may be requested by calling 2-1-1 or 877-541-7905.

3360 Patient Navigation Services

Revision 25-3; Effective Sept. 1, 2025

Patient navigation is defined as individualized assistance provided to women to help overcome barriers and facilitate timely access to quality screening and diagnostic services and initiate timely treatment for those diagnosed with cancer.

Patient Navigation Activities

Although patient navigation services vary based on a client’s needs, at a minimum, patient navigation for women served by the BCCS program must include the following:

  • an assessment of the client’s barriers to cancer screening, diagnostic services and initiation of cancer treatment;
  • client education and support;
  • resolution of client barriers such as transportation and translation services;
  • client tracking and follow-up to monitor progress in completing screening, diagnostic testing and initiating cancer treatment;
  • a minimum of two, but preferably more, contacts with the client;
  • collection of data to evaluate the primary outcomes of patient navigation, such as client adherence to cancer screening, diagnostic testing and treatment initiation; and
  • tracking of clients lost to follow-up.

Assessment is a cooperative effort between the client and patient navigator to examine and document the client’s needs, such as diagnostic, treatment, and essential support services through a process of gathering critical information from the client.

Planning uses short- and long-term needs identified in the assessment to establish planned services, time frames, and follow-up. As applicable, time frames must be consistent with BCCS required screening and diagnostic intervals. Services must be completed no later than 30 days from the date of the planned activity or before initiation of treatment, whichever is sooner.

Coordination is the implementation of the service plan, which includes the appropriate use of available resources to meet the client’s needs. Coordination of services may include scheduling appointments, making referrals, and obtaining and disseminating appropriate reports.

Monitoring is the ongoing assessment of the client’s service plan to make sure the client’s needs are met. In addition to monitoring clients who are receiving patient navigation services, grantees must establish a system to monitor abnormal screening or diagnostic results that identifies clients who need to have patient navigation initiated.

Resource Development

Patient navigators are responsible for identifying resources to meet client needs, including dysplasia and cancer treatment services, regardless of client ability to pay. Documentation must be maintained in a resource directory developed specifically to detail services that support BCCS-enrolled women with unmet needs.

Grantee Requirements

All women enrolled in BCCS must be assessed for their need of patient navigation services and provided with such services accordingly. Grantees are required to provide patient navigation services to:

  • BCCS-enrolled clients with abnormal screening or diagnostic results;
  • clients referred to BCCS with qualifying breast or cervical cancer diagnoses that are presumptively eligible for Medicaid for Breast and Cervical Cancer (MBCC); and
  • clients referred to BCCS for cervical dysplasia management and treatment. Cervical dysplasia recipients must not be eligible for MBCC.

Patient navigation does not include eligibility determination or navigation of MBCC applicants whose presumptive eligibility determination was inaccurate.

Terminating Patient Navigation

Depending on screening and diagnostic outcomes, patient navigation services are terminated when a client:

  • completes screening and has a normal result;
  • completes diagnostic testing and has normal results;
  • has attended a referral appointment for treatment;
  • is documented as lost to follow-up or refused services;
  • has had a good faith effort made per BCCS policy; or
  • initiates or refuses cancer treatment.

When a client concludes her cancer treatment and has been released by her treating physician to return to a routine screening schedule, she may return to the program and receive all services, including patient navigation, if she continues to meet BCCS eligibility requirements.

Requirements for Patient Navigation Compliance

Navigation of patients must meet the following requirements:

  • Patient navigation must include an assessment for needs and care coordination planning.
  • The assessment is to be conducted within 30 days from the date of referral for diagnostic procedures, or before the initiation of the first diagnostic service, whichever is sooner.
  • The assessment should be conducted in person, by phone, or with virtual telehealth software in a face-to-face interview format if possible.
  • The service plan must be documented in the Med-IT® Data System Navigation screen and the client’s office progress notes.
  • The grantee must make sure monitoring of abnormal results is conducted and documented at the grantee level.
  • The grantee must contact clients with abnormal screening and noncancerous diagnostic results no later than 30 days following receipt of an abnormal result. All screening and diagnostic services must be documented, including procedure-specific consent if applicable.
  • The grantee must contact clients with cancer diagnoses no later than two weeks following the receipt of a cancer diagnostic result. All screening and diagnostic services must be documented, including procedure-specific consent, if applicable.
  • Within one month after completion of the patient navigation plan for a diagnosis of cancer or cervical dysplasia, the patient navigator must follow-up and document that the service was implemented.
  • As more needs are identified, they are recorded on the plan and the accompanying services and time frames are indicated.
  • Grantees must develop and maintain a resource directory that contains information on services that could support women with unmet needs who are eligible for BCCS.
  • Grantees must document client refusal, loss to follow-up, and good faith effort as appropriate.

Navigation of MBCC Referrals

Referred MBCC applicants must be provided a needs assessment and MBCC application assistance if determined to meet presumptive eligibility. BCCS grantees may choose to provide patient navigation for MBCC referrals that were determined to be ineligible. If patient navigation is initiated for a client found to be ineligible for MBCC, BCCS grantees must follow the client until treatment is initiated but may not bill BCCS for the patient navigation services provided. If patient navigation will not be initiated, the client should be provided with information about available local resources and referred to the diagnosing health professional.

Good Faith Effort

A good faith effort is defined as at least three documented attempts to get treatment or to navigate clients with a precancerous or cancerous breast or cervical diagnoses who do not meet the eligibility criteria for cervical dysplasia or MBCC enrollment. Examples include seeking service(s) for clients through the American Cancer Society, Susan G. Komen for the Cure, Livestrong, other health care providers and facilities through pro bono, sliding fee scale, reduced payment plan or sponsorship assistance.

3361 Client Refusal of Services

Revision 23-2; Effective Sept. 29, 2023

The grantee must attempt to obtain, in writing, and document in the client record informed refusal from the client if the client fails to keep appointments or refuses recommended procedures. If the client cannot, or will not, sign an informed refusal, the grantee must document verbal refusal. Before closing the client record as a refusal, a thorough review of the client’s plan, recommendations and navigator's actions must be conducted to ensure proper closure.

Lost to Follow-up

Before a grantee can consider a client as lost to follow-up, the grantee must have at least three documented attempts to contact the client, with the last attempt sent by certified mail. The grantee must allow enough time between contact attempts for the client to reply or respond to the grantee.

Client contact attempts can be made by:

  • office visit;
  • phone;
  • home visit;
  • mail; or
  • a combination of these methods.

Attempts to contact the client must be written or presented verbally (when appropriate) in the client’s primary language (if the client has limited English proficiency) and must include appropriate provisions for the visually and hearing impaired.