Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement. The NC Division of Medical Assistance (DMA) is required to cover services, products, or procedures for Medicaid beneficiaries under 21 years of age if the service is medically necessary health care to correct or ameliorate (improve) a defect, physical or mental illness, or a condition (health problem) identified through a screening examination**
**(includes any evaluation by a physician or other licensed clinician).
The full array of EPSDT services must be coverable within the scope of those listed in the federal law at 42 U.S.C. § 1396d (a) 1905(a) of the Social Security Act.
Services covered by EPSDT must:
- Be determined to be medical in nature
- Be generally recognized as an accepted method of medical practice or treatment
- Not be experimental or investigational
- Be safe
- Be effective
EPSDT covers short-term and long-term services as long as the requested services will correct or ameliorate (improve) the child’s condition. For example, a service must be covered under EPSDT if it is necessary for immediate relief (e.g., pain medication). Treatment need not ameliorate (improve) the child’s condition taken as a whole, but need only be medically necessary to ameliorate (improve) one of the child’s diagnoses or medical conditions.
The specific coverage criteria (e.g., particular diagnoses, signs, or symptoms) in the DMA Clinical Coverage Policies or Service Definitions do NOT have to be met for recipients less than 21 years if the service is medically necessary to correct or ameliorate (improve) a defect, physical or mental illness, or condition. In addition, the specific numerical limits (number of hours, number of visits, or other limitations on scope, amount or frequency) in DMA Clinical Coverage Policies, Service Definitions, or billing codes do NOT apply to recipients under 21 years of age if more hours or visits of the requested service are medically necessary to correct or ameliorate (improve) a defect, physical or mental illness, or condition. Other restrictions in DMA’s Clinical Coverage Policies, such as the location of the service (e.g., Personal Care Services delivered only in the home), prohibitions on multiple services on the same day or at the same time (e.g., Day Treatment and Residential Treatment) must also be waived under EPSDT as long as the services are medically necessary to correct or ameliorate a defect, physical or mental illness, or condition.
No request for services for a recipient under 21 years of age will be denied, formally or informally, until it is evaluated under EPSDT.
Services provided in the NC Innovations waiver are available only to participants in the Innovations waiver programs and are not a part of the EPSDT benefit unless the waiver service is ALSO an EPSDT service.
ANY child enrolled in an Innovations program can receive BOTH waiver services and EPSDT services.
However, the cost of the recipient’s care must not exceed the waiver cost limit.
It is important to remember that EPSDT does NOT eliminate the need for prior approval if prior approval is required.
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. When Utilization Management staff review a covered state Medicaid plan services request for prior approval or continuing authorization for an individual under 21 years of age, the reviewer will apply the EPSDT criteria. In addition, for 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.
Documentation submitted by providers in an authorization request for either covered or non-covered state Medicaid plan services should show how the service will correct or ameliorate a defect, physical or mental illness, or a condition. This includes:
- Documentation showing that policy criteria are met
- Documentation to support that all EPSDT criteria are met
- Evidence-based literature to support the request, if available
Should additional information be required, the provider will be contacted.
If covered or non-covered services are denied, reduced, or terminated, the recipient will receive a proper written notice with appeal rights. This information will also be copied to the provider. The notice must include reasons for the intended action, a law that supports the intended action, and notice of the right to appeal. Such a denial can be appealed in the same manner as any Medicaid service denial, reduction, or termination.
For additional detailed information on EPSDT, you can contact Partners’ Utilization Management Department by calling 1-877-864-1454.
You can also learn more at http://www.ncdhhs.gov