• The service must be within the scope of those listed in the Social Security Act (42 U.S.C. 1396d(a)).
• The service must be medically necessary to correct or improve a defect, physical or mental illness, or a condition diagnosed by the recipient’s physician, therapist or other licensed practitioner.
• The requested service must be a medical service.
• The service must be safe.
• The service must be effective.
• The service must be generally recognized as an accepted method of medical practice or treatment.
• The service must not be experimental or investigational.

Additionally, services can only be covered if they are provided by a North Carolina Medicaid enrolled provider for the specific service type. This may include an out-of-state provider who is willing to enroll if an in-state provider is not available.

EPSDT applies to short-term and long-term services, as long as the treatment will correct or improve the individual’s condition. For example, EPSDT may cover services that relieve immediate symptoms (e.g., pain management) or services that address a chronic or developmental condition.

• Children and Youth under age 21 who are enrolled in Medicaid qualify to receive EPSDT services.

• Specific coverage criteria in NC Medicaid Clinical Coverage Policies or Service Definitions do not restrict EPSDT services for members under 21 if the requested service is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition.
• Numerical limits (e.g., number of hours, visits, or frequency caps) do not apply if more is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition.
• Other restrictions (such as service location requirements or prohibitions on concurrent services) must be waived if the service is medically necessary under EPSDT.
• No service request for an individual under 21 may be denied until it has been reviewed using EPSDT criteria.

• EPSDT does not remove the requirement for prior approval when a service normally requires it under Medicaid.
• Requests for EPSDT services do not have to be labeled as such. Any proper request for services for a recipient under 21 years of age is a request for EPSDT services.
• Recipients less than 21 years of age enrolled in the Innovations waiver, a request for services must be considered under EPSDT as well as under the waiver.
• When a provider submits a prior approval or authorization request for a recipient under 21, utilization management must apply EPSDT criteria, even if the service is not covered under the State Plan.
• Documentation should clearly show how the service meets EPSDT criteria:
  • Evidence showing how the service will correct or ameliorate a defect, illness or condition.
  • Documentation that policy criteria are met, if applicable.
  • Clinical or evidence-based literature supporting the request, if available.
• If additional information is needed, providers may be contacted for clarifications.

If services for a recipient under 21 are denied, reduced, or terminated:

• A written notice will be sent to the member and provider.
• The notice must explain the reason, cite the legal basis and outline appeal rights.
• Appeals follow the same process as any Medicaid service denial, reduction or termination.

• If an MCO’s network does not have the capacity to provide a required EPSDT service timely, an out-of-network provider must be covered.

EPSDT coverage includes medically necessary behavioral health and developmental services, including:

• Autism spectrum disorder treatments.
• Research-based intensive behavioral interventions.
• Therapies that exceed standard limits.

• Services available through the NC Innovations waiver are limited to waiver participants.
• However, an individual enrolled in the Innovations waiver can receive both waiver services and EPSDT services.
• The total cost of care cannot exceed the waiver cost limit.

(CAA § 5121, 2025 Update)

Per the Consolidated Appropriations Act § 5121, EPSDT obligations extend to certain juveniles in correctional settings. MCOs must ensure EPSDT screening and treatment requirements are met for eligible youth.

Non-Covered State Plan Services for Under 21 Prior Approval Request Form

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

• Covers the definition of EPSDT, Partners’ requirements, the periodicity schedule, diagnostic and treatment components, medical necessity review, coordination with programs (VFC, IMB, NC Infant-Toddler) and key operational elements such as codes, modifiers, referrals, tracking, follow-up and outreach.