Susan G. Komen San Diego’s Breast Health Diagnostic Services Program
Referring Health Centers & Providers
Participating agencies must be community health centers/federally qualified health centers or Every Woman Counts (EWC) providers. Referring agencies are responsible for screening the patient for eligibility. If applicable, please continue to refer your patient to Medi-Cal enrollment specialists before accessing this program.
To receive services from the Komen SD Breast Health Diagnostic Program, the patient must:
Be a resident of San Diego County
Not be eligible for Every Woman Counts (OR Every Woman Counts patients who need an MRI)
Not be eligible for Medi-Cal
Be at or below 300% of the federal poverty guidelines, click here to see the chart for income guidelines.
All authorization requests must be submitted to Komen San Diego by the referring health center
All services must be pre-authorized by Komen San Diego for the diagnostic services to receive payment
All requests must be selected from the List of Covered Procedures (below)
Only services from this list will be authorized
All authorizations will expire 90 days after the date issued
Forms must be filled out completely and legibly
The patient must sign a Medical Release Form from the referring health center, naming Susan G. Komen San Diego
Include referring health center fax number or email on the request so the response can be returned within 48 business hours
Indicate the name of the diagnostic facility or provider who will provide the diagnostic service
The referring health center is responsible for making all necessary appointments
The referring health center is responsible for providing a copy of the authorization request to the diagnostic services provider
While we have tried to keep the process and authorization request forms as similar as possible to the ones you may be accustomed to from Health Quality Partners, there are a few important changes:
We are now requiring that each patient accessing this program sign a medical release form from the provider naming Susan G. Komen San Diego.
The patient no longer needs to sign the authorization request form.
Surgical consults are no longer required prior to MRI.
All authorization requests need to be faxed to (858) 751-5760 or emailed to firstname.lastname@example.org or mailed to Claims Department, Susan G. Komen San Diego, 4699 Murphy Canyon Road, suite 102, San Diego, Ca 92123
To access the program for eligible patients, you must first have a signed agreement with Komen San Diego (please contact email@example.com for the agreement), and request authorization from Komen San Diego for any of the diagnostic services listed on the below List of Covered Procedures for 2018. Please submit a completed authorization request form to the fax number, email or mailing address at the bottom of the form.
Thank you for the service you provide to the community. We look forward to working together to continue to provide access to breast health diagnostics in San Diego County. Please do not hesitate to reach out with any questions to Lizzie Wittig at (858) 573-2760 x104 or firstname.lastname@example.org.