Early and Periodic Screening, Diagnosis and …

1 Washington Apple Health (Medicaid) Early and Periodic screening Diagnosis and treatment ( epsdt ) Program Billing Guide October 1, 2017 Every effort has been made to ensure this guide s accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply. Early and Periodic screening Diagnosis and treatment ( epsdt ) Program 2 About this guide* This publication takes effect October 1, 2017, and supersedes earlier guides to this program. HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services.

2 Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority. What has changed? Subject Change Reason for Change Fully Integrated Managed Care (FIMC) Effective January 1, 2018, the agency is implementing a second FIMC region, the North Central (NC) region, which includes Douglas, Chelan, and Grant Counties. The agency has updated and consolidated the FIMC information in this guide and provided several hyperlinks to the agency s Managed Care webpage, the agency s Integrated physical and behavioral health care webpage, and the agency s Regional resource webpage.

3 Notification of new region moving to fully integrated managed care (FIMC) * This publication is a billing instruction. Early and Periodic screening Diagnosis and treatment ( epsdt ) Program 3 How can I get agency provider documents? To access provider alerts, go to the agency s provider alerts web page. To access provider documents, go to the agency s provider billing guides and fee schedules w eb page. Where can I download agency forms? To download an agency provider form, go to HCA s Billers and providers web page, select Forms & publications. Type the HCA form number into the Search box as shown below (Example: 13-835). Copyright disclosure Current Procedural Terminology (CPT) copyright 2016 American Medical Association (AMA).

4 All rights reserved. CPT is a registered trademark of the American Medical Association. Fee schedules, relative value units, conversion factors or related components, or both, are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Early and Periodic screening Diagnosis and treatment ( epsdt ) Program Alert! This Table of Contents is automated. Click on a page number to go directly to the page. 4 Table of Contents How can I get agency provider documents? ..3 Where can I download agency forms? ..3 Resources Available ..6 Program Overview ..7 Who can provide epsdt screenings? ..7 Client Eligibility.

5 8 Who is eligible for epsdt screenings?..8 How can I verify a patient s eligibility? ..8 Are managed care clients eligible for epsdt screenings? ..9 Effective July 1, 2017, not all Apple Health clients were enrolled in a BHO/FIMC/BHSO ..10 Effective January 1, 2017, some fee-for-service clients who have other primary health insurance will be enrolled into managed care ..10 Effective April 1, 2016, important changes to Apple Health ..11 New MCO enrollment policy earlier enrollment ..11 How does this policy affect providers? ..11 Behavioral Health Organization (BHO) ..12 Fully Integrated Managed Care (FIMC) ..12 FIMC Regions ..13 Apple Health Core Connections (AHCC)..13 AHCC complex mental health and substance use disorder services ..14 Contact Information for Southwest Washington ..14 What if an infant has not yet been assigned a ProviderOne Client ID?

6 15 epsdt Screenings ..16 What are epsdt screenings? ..16 What is included in an epsdt screening ? ..16 What are the requirements for developmental screening and surveillance and screening for autism? ..17 What additional screening components may be billed? ..18 How often should epsdt screenings occur? ..18 How much does the agency pay for epsdt screenings for foster care children? ..19 Where do I find the client s placement in the client record? ..20 What is the purpose of a foster child initial health evaluation? ..20 Who is eligible for an IHE? ..20 What is included in an IHE? ..21 What fee does the agency pay for an IHE? ..21 How do I bill for an IHE? ..22 What are the documentation requirements for an IHE? ..22 Early and Periodic screening Diagnosis and treatment ( epsdt ) Program Alert!

7 This Table of Contents is automated. Click on a page number to go directly to the page. 5 What are the time limits for scheduling requests for epsdt screenings? ..23 What if a problem is identified during a screening examination? ..23 What is extended developmental testing? ..24 How is genetic counseling and genetic testing billed? ..24 How are referrals made? ..24 Chiropractic services ..24 Dental services ..25 Orthodontics ..25 Lead toxicity screening ..25 Fetal alcohol syndrome (FAS) screening ..25 Washington State FAS clinic Medical nutrition therapy ..26 Does the agency pay for fluoride varnish application? ..27 Who may prescribe the fluoride varnish? ..27 Who is eligible for fluoride varnish? ..27 Are managed care clients eligible for fluoride varnish? ..27 Mental Health and Substance Abuse Assessments.

8 28 Is mental health screening part of the epsdt screening process? ..28 screening guidelines ..28 Urgent referrals ..29 Nonurgent referral ..29 How are substance abuse screening and treatment provided? ..30 screening , Brief Intervention, and Referral to treatment (SBIRT) ..30 Washington Recovery Help Line ..30 epsdt mental health/substance abuse assessment referral EXAMPLE referral explanation for teen or Immunizations ..33 How do I bill for vaccines when clients are age 19 and 20? ..33 What vaccines are free from DOH for clients age 18 and younger? ..33 How do I bill for vaccines that are not free from DOH for clients age 18 and younger? ..34 General Authorization ..35 What is prior authorization (PA)? ..35 What is a limitation extension (LE)? ..35 How do I obtain written authorization?

9 35 Billing ..36 How do I bill claims electronically? ..36 What are the billing requirements specific to epsdt ? ..37 Early and Periodic screening Diagnosis and treatment ( epsdt ) Program 6 Resources Available Topic Contact Where can I find information on becoming an agency provider? See the agency s ProviderOne Billing and Resource Guide. Questions on payments, denials, general questions regarding claims processing, or agency-contracted managed care organization (MCO) Submitting claims for payment Questions on private insurance or third-party liability, other than agency-contracted managed care plans Questions about prior authorization, limitation extensions, or exception to rule Referral for Mental Health Behavioral Health Organization (BHO). Referral for Substance Abuse Assessment Washington Recovery Help Line Where is the epsdt Fee Schedule?

10 See the agency s epsdt Fee Schedule Obtaining prior authorization or a limitation extension For all requests for prior authorization or limitation extension, submit: A completed, typed General Information for Authorization form, HCA 13-835. This request form must be the initial page when you submit your request. A completed Fax/Written Request Basic Information form, HCA 13-756, and all the documentation listed on this form and any other medical justification. Fax your request to: 866-668-1214. See Where can I download agency forms? Early and Periodic screening Diagnosis and treatment ( epsdt ) Program 7 Program Overview Title 42 CFR, Part 441, Subpart B Early and Periodic screening , Diagnosis and treatment ( epsdt ) is a federal preventive health care benefit. The purpose of this program is to periodically screen clients age 20 and younger to detect physical and mental health problems.