Early and Periodic Screening, Diagnosis and …

1 Early and Periodic screening , Diagnosis and treatment January 2017. Overview Program Description Eligible Providers Member Eligibility EPSDT Services EPSDT Transportation EPSDT Billing 2. Early and Periodic screening , Diagnosis and treatment Services (EPSDT). The goal of the Early Periodic screening , Diagnostic and treatment (EPSDT) program, also known as the Alaska Well Child Program, is to ensure that all Medicaid and Denali KidCare- eligible children receive the health care they need, when they need it. The EPSDT program's focus is on promoting the physical, mental, social, emotional and behavioral health. Services are available to all Medicaid/Denali KidCare-eligibile children under age 21. 3. What is EPSDT? 4. EPSDT Services EPSDT is a federally mandated child health component of Medicaid CMS measures Alaska's participation in this program using associated procedure codes and publishes EPSDT findings for the nation and each state annually EPSDT findings can be found at It is essential that providers use the appropriate screening codes found in the EPSDT fee schedule Alaska Medicaid reimburses enrolled providers for medically necessary services for eligible members when delivered, ordered or prescribed by a provider within the scope of the provider's license or certification Prescribing, ordering or referring provider must also be enrolled as an Alaska Medicaid provider 5.

2 EPSDT Program Information 6. Eligible Providers 7. EPSDT Providers The following providers may be reimbursed for EPSDT screenings and related services within the scope of their license or certification, but must first enroll as an Alaska Medicaid provider: Physician Advanced Nurse Practitioner (ANP). Physician Assistant (PA) or other licensed or certified health care practitioner under physician supervision Alaska Division of Public Health Indian Health Service/Tribal Clinic Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC). Municipal health department School district 8. Member Eligibility 9. Member Eligibility 10. Member Eligibility Always verify member eligibility by using one of the following options: Request to see the member's eligibility coupon or card that shows the current month of eligibility; photocopy for your records Call Automated Voice Response System (AVR): (toll-free). Verify via Alaska Medicaid Health Enterprise website Fax complete Recipient Eligibility Inquiry Form - General Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction Call Provider Inquiry , option 1 or , option 1, 1 (toll-free).

3 11. EPSDT Services 12. Fee Schedules Fee schedules tell you: What services are covered Maximum allowed reimbursement Additional documentation requirements Other special considerations Fee schedules can be found on in the Documents & Forms section 13. Service Authorizations Recommended EPSDT screenings do not require a service authorization Provider service recommendations following an EPSDT screening may require a service authorization. Refer to the applicable provider fee schedule ( , Physician/ANP/PA, Vision, or Hearing) to determine whether a service authorization for the covered EPSDT. service is required for that particular provider type 14. EPSDT Screenings At minimum, an EPSDT screening must consist of a comprehensive medical screening that includes a health and developmental history, anticipatory guidance as needed, and the following screenings at age-appropriate intervals or as indicated: Dental Developmental/behavioral screening and assessment Hearing Vision Lead screening at age 12 and 24 months Any other tests and procedures that are age-appropriate and medically necessary 15.

4 EPSDT Screenings (cont.). EPSDT screenings should comply with the minimum recommendations of the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Care periodicity schedule, with the exception of lead screening which must occur at 12 and 24. months When screening indicates the need for further evaluation, the screener must provide follow-up care within scope of their license, or refer the member to an enrolled provider for follow-up care without delay 16. Bright Futures Website 17. Bright Futures/AAP Periodicity Schedule Early CHILDHOOD. 12 mo 15 mo 18 mo 24 mo 30 mo 3y 4y Vision 7. Hearing 18. Comprehensive Medical screening A comprehensive medical screening or well child checkup must include a health and developmental history, comprehensive unclothed physical examination, and all age appropriate screenings and tests. As part of the screening process, providers should: Document the assessments and significant findings in the member's medical record Discuss the findings with the child and family Refer the member to another enrolled provider to complete the screening if the provider is unable to perform any screening components Other necessary or required blood panels, screenings, or specimen collection should be performed during the screening 19.

5 Dental screening Oral health screenings should begin at age 6 months At age 3, a child who is not already under a dentist's care must be referred for a dental examination The following provider types who have appropriate training may perform dental fluoride application and oral evaluations: Dentists Dental Health Aide Technicians (DHAT). Physician/ANP/PA. Community Health Aides/Practitioners (CHA/P). Non-dental providers must complete an Oral Health or Caries Risk Assessment training program and retain a certificate of completion 20. Dental screening (cont.). Alaska Medicaid covers a maximum of four fluoride varnish applications per calendar year Oral evaluations are limited to one per year for eligible children ages 3 21 and two per year for eligible children under age 3. 21. Developmental screening and Assessment Minimum Recommendations for Development screening and Surveillance Standardized developmental screening should be administered at the 9 month, 18 month and 30 month visits Autism screening should be administered at the 18 month and 24 month visits Developmental surveillance is a cumulative and continuous process that should be performed at every preventive visit throughout childhood and adolescence In all cases, additional screenings should be performed when surveillance demonstrates risk or when any concerns arise during surveillance Any concerns should be referred to the local Early Intervention/Alaska Infant Learning Program or other appropriate health care provider 22.

6 Developmental screening and Assessment (cont.). The Department of Health and Social Services recommends the use of these validated standardized screening tools: Ages and Stages Questionnaire (ASQ) for 2 months to 5 years Ages and Stages Questionnaire 3rd Edition (ASQ-3) for 2 months to 5 years Battelle Developmental Inventory screening Tool for birth to 95 months Bayley Infant Neuro-developmental Screen for 3 months to 2 years Brigance Screens-II for birth to 90 months Child Development Inventory for 18 months to 6 years Infant Development Inventory for birth to 18 months Parents' Evaluation of Developmental Status for birth to 8 years Parents' Evaluation of Developmental Status Developmental Milestones 23. Developmental screening and Assessment (cont.). Completion of the screening Tool The screening tool may be completed by the parent/guardian or other healthcare staff, but must be reviewed by one of the following: Physician/ANP/PA.

7 Physical or occupational therapist Speech language pathologist Audiologist Psychologist or psychological associate Community health aide (Level III or Level IV). EPSDT screener Public health nurse Coverage of screening services is limited to 2 screenings per visit 24. Hearing screening Providers should perform hearing screenings to their level of training or refer member to another Alaska Medicaid-enrolled provider who can complete the screening If medically necessary, audiology services should be ordered or prescribed Alaska Medicaid covers hearing aids as well as repairs or replacement 25. Vision screening EPSDT screeners should perform a vision screening to their level of training or refer the member to another Alaska Medicaid-enrolled provider who can complete the screening If screening results indicate a need for treatment of a defect, refer the child to a vision care provider 26. screening and Brief Intervention Services screening , Brief Intervention and Referral to treatment (SBIRT) is a three-part approach to drug and substance abuse intervention SBIRT services can Decrease the frequency and severity of drug and alcohol use Reduce the risk of trauma Increase the probability that patients who need specialized substance abuse treatment will receive it Alcohol and drug use screening should be incorporated in the EPSDT screenings starting at age 11 when surveillance indicates risk or when any concerns arise during surveillance The Substance Abuse and Mental Health Services Association (SAMHSA) provides screening instruments and tools for providers at 27.

8 EPSDT Referrals, Diagnosis and treatment When an EPSDT screening indicates the need for further evaluation, the healthcare provider performing the screening must, without delay: Refer the member to an enrolled provider for follow-up care Provide follow-up care within scope of his or her license Alaska Medicaid covers all referrals and follow-up care made during the EPSDT screening for a medical need Alaska Medicaid covers medically necessary diagnostic services and treatment of all physical and mental illnesses and conditions discovered by any screening and diagnostic procedure Some services and/or treatments may require a service authorization. Refer to the applicable provider fee schedule ( Physician/ANP/PA, Vision, or Hearing) to determine whether a service authorization is required. 28. EPSDT Referrals, Diagnosis and treatment Referral Guide: Services Available to Eligible Children Category of Service Description of Covered Service Audiology Testing and treatment by an audiologist.

9 Hearing aids, batteries and repairs Behavioral Health EPSDT screenings can include brief intervention services; refer to screening and Brief Intervention Services in this section. Behavioral health assessment, evaluation and treatment provided by a psychiatrist (MD), mental health physician clinic, or community behavioral health clinic. Chiropractic Spinal manipulations and x-rays. Service authorization required for children under six years old. Dental Exams, x-rays, cleaning, fluoride treatments, sealants, fillings, surgical and restorative services, and limited orthodontia services. Developmental Covered when provided by a certified Infant Learning Program, school district, physician, Assessment advanced nurse practitioner, or public health nurse. Family Planning Medical services, prescription birth control supplies and over-the-counter birth control supplies with a prescription from teen's provider. Hospital Most services.

10 Lab tests and/or x-rays ordered by health care provider. Emergency room and outpatient surgery. Services may require authorization by physician. Immunization Administration of medically necessary immunizations and vaccinations. 29. EPSDT Referrals, Diagnosis and treatment Referral Guide: Services Available to Eligible Children Category of Service Description of Covered Service Medical Supplies and Some items need to be authorized; health care provider can request service Equipment authorization. Nutrition High risk children and pregnant or breastfeeding teens can get services from a registered dietician with a referral from WIC or a physician, advanced nurse practitioner, or physician assistant. Physical Therapy and Evaluation and treatment . Occupational Therapy Podiatry Ankle and foot services. Pregnancy Care Regular prenatal care; hospital delivery costs. Prescription Medications Alaska Medicaid offers comprehensive drug coverage; refer to the Pharmacy Billing Manual for details.