Colorectal Cancer Screening Reimbursement
Customize your policy alerts
Sign up for University Health Alliance (HSA) Policy MPP-0025-120301 alerts
Get alerted when Policy MPP-0025-120301 changes without checking for updates manually.
Monitor payer policy activity
Defines University Health Alliance (UHA) reimbursement coverage, limitations, and administrative requirements for colorectal cancer (CRC) screening for members, including covered screening modalities and prior authorization rules.
No material clinical or coverage changes in this revision.
Coverage Criteria
Primary coverage criteria
Covered when ALL of the following apply:
ALL of the following
- Age 40 through 85: average-risk individuals are eligible for routine CRC screening (ages <40 or >85 may be considered with documentation)
See individualized decision criteria for ages 76–85
ALL of the following
- Screening in adults 76–85 should be an individualized decision based on overall health and prior screening history
- Prefer screening for adults in this age range who have never been screened and who are healthy enough to undergo treatment if cancer is detected and do not have comorbid conditions that significantly limit life expectancy
ALL of the following
ONE OF
- Colonoscopy every 10 years
- High-sensitivity fecal occult blood testing (FOBT) including guaiac or FIT every calendar year
- Fecal DNA testing (Cologuard/FIT-DNA) once every 3 years
Cologuard requires prior authorization and is not appropriate for symptomatic or high‑risk individuals or when another USPSTF-recommended modality has been completed within its interval
- Flexible sigmoidoscopy every 5 years
- Flexible sigmoidoscopy every 10 years plus annual FIT
ALL of the following
- Virtual (CT) colonoscopy is not covered for screening except as specified in the separate Virtual (CT) Colonoscopy payment policy
- Anesthesia services are covered only for special indications as outlined in the separate Anesthesia Services for Gastrointestinal Endoscopic Procedures policy
- Routine screening stops applying after a diagnosis of colorectal adenomas or cancer; patients on surveillance regimens are managed under surveillance guidance
- Routine screening outside ages 40–85 may be covered with supporting documentation in individual cases
ALL of the following
- Prior authorization is required for Cologuard; submit requests via UHA's online portal (contact UHA to establish a login if needed)
- UHA may cover Cologuard once every 3 years for members aged 50–85 at average risk
- Cologuard is NOT covered for members who have symptoms suggestive of colon cancer, members with a prior positive colonoscopy finding of polyps or cancer, or members with a high‑risk family history of colon cancer
- Cologuard will not be covered if the member has completed any other USPSTF‑recommended CRC screening modality during its recommended interval
ALL of the following
- Prior authorization is not required for CRC screening generally, except for Cologuard
- Supporting documentation should be maintained in the medical record and available to UHA upon request; UHA may perform retrospective review to validate payment determinations
Screening Modalities & Coding
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
Provider Actions & Prior Authorization
Cologuard (FIT‑DNA) requires prior authorization
Prior authorization is not required for colorectal cancer (CRC) screening in general; however, Cologuard (FIT‑DNA) testing requires prior authorization and may be covered once every 3 years for members aged 50–85 at average risk. To request prior authorization for Cologuard, submit via UHA's online portal; if a login has not been established, contact UHA at 808‑532‑4000 to establish one.
- Cologuard is not appropriate and will not be covered for members with symptoms related to colon cancer, with a positive colonoscopy finding of polyps or cancer, or with a high‑risk family history.
- Cologuard will not be covered if the member has completed any other USPSTF‑recommended CRC screening modality during its recommended interval.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.