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Billing and Claims


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.