Billing and Claims

Claims

NEW* ScreenWise Billing Requirements
How to Submit Claims to ScreenWise (pdf)
New Secure Portal Access Instructions (pdf)
Payment Status Resources (pdf)
2023 EOB and PDR Schedule
Contact Form New! : Use form to update clinic contact information
If Your Patient Receives a Bill: Information and instruction sheet for resolving patient being billed

Claim Forms

ScreenWise Claim Forms are optional tools for billing ScreenWise Program services. These forms are not required and providers are encouraged to submit claims in the manner that best works for their clinic.

Covered Services

Reimbursement schedule includes all CPT and ICD-10 diagnosis codes accepted by the program.

Optional Forms

Referral Form. This document is a new tool for referrals to services (including mammograms). This is not required, but a tool to support ScreenWise providers as we transition away from the voucher system.
Request for Clinical Exception Form. If you have a recommended procedure that is not on our CPT code list, you can use this form to request an exception.
Out-of-Pocket Form - English
Out of Pocket Form - Spanish
Program Participant Referral Stamps