EPSDT-referred services must be covered (EPSDT-only enrollment)

EPSDT-referred services that are medically necessary must be covered even if they are not ordinarily provided in the State Plan; providers not ordinarily enrolled will be enrolled as “EPSDT-only” referred care and must maintain the EPSDT referral form for services provided as a result of a screening.

• Services identified as medically necessary during an EPSDT screening are covered even when not listed in the State Plan.
• Providers of services not ordinarily provided will be enrolled to provide “EPSDT-only” referred care.
• An EPSDT referral form must be maintained by the provider for services provided as a result of a screening.

Prior authorization required for specified therapy codes, all PDN and personal care

Some therapy procedure codes and all private duty nursing (PDN) and personal care services require prior authorization; all PDN services require prior authorization and recipients must be under age 21 and Medicaid eligible.

• Some PT/OT/ST/other therapy codes may require prior authorization before services are rendered (see respective billing manuals).
• All private duty nursing services require prior authorization; recipient must be under 21 and Medicaid eligible and require at least four consecutive hours of skilled nursing care.
• Personal care services require prior authorization and must be ordered for conditions identified during an EPSDT screening.

Reimbursement above limits for screening referrals when medically necessary

When a screening provider refers a person for diagnosis or treatment, services necessary to treat or ameliorate the condition identified in the screen will be considered for reimbursement above current limitations, provided they are medically necessary.

• Reimbursement consideration above usual limits applies only when services are medically necessary to treat/ameliorate a condition identified in the EPSDT screen.
• EPSDT-only providers must be used for services not ordinarily provided as Medicaid benefits for children under 21.

Supervising therapists/licensees assume responsibility and bill; assistants provide delegated services under supervision

Supervising therapists and licensed behavior analysts must assume professional responsibility and submit claims; assistants may deliver delegated tasks under specified supervision but may not initiate or alter treatment plans.

• The supervising/licensed practitioner must oversee assistants and document scheduled supervisory visits (PT: sign supervisory visits at minimum every 6th visit; OT: specified minimum on-site supervision hours).
• Licensed Behavior Analysts must supervise according to Behavior Analyst Certification Board requirements and submit claims; licensed practitioner assumes responsibility for services delivered by assistants or RBTs.

Recordkeeping for Screening Provider Manual procedures/tests

All procedures and tests listed in the Screening Provider Manual must be performed and recorded in the individual’s case history; if a procedure/test is not performed the reason must be recorded, and records are subject to audit.

• Record each procedure/test in the case history of the individual.
• If a procedure/test cannot be carried out, document that fact and the reason in the case history.
• Failure to meet these documentation requirements may lead to recoupment following audits or on-site visits.

Referring provider must document screening-identified conditions in medical record

Referring providers must document the condition(s) identified during the EPSDT screening in the patient’s medical history or physical exam portion of the medical record; notation only on the EPSDT referral form is insufficient and may lead to recoupment.

• Document conditions in the medical history or physical examination portion of the record — referral form notation alone is not enough.
• Medicaid may recoup payment for the screening service when a referral is made for a condition not documented in the medical history or physical exam.

EPSDT-only providers must maintain detailed treatment plan in recipient record

EPSDT-only providers must develop and maintain a treatment plan in the recipient’s medical record that includes required identifying and treatment items (recipient name, Medicaid number, date of EPSDT screening, referring physician, diagnoses, onset date, surgery details if applicable, functional status, expected status after treatment, frequency/duration, modalities, and ulcer specifics when applicable).

• Treatment plan must be readily available in the recipient's medical record for review.
• Include at minimum: recipient name; current Medicaid number; date of EPSDT screening; referring physician; diagnosis(es); date of onset/acute exacerbation; surgery type/date (if applicable); functional status prior and expected after treatment; frequency and duration of treatment; modalities; for ulcers — location, size and depth.

PDN providers must maintain signed service logs, document missed visits/substitutes, and submit required forms

Private Duty Nursing (PDN) providers must maintain signed service logs with date/time entries signed by the nurse and caregiver, retain a copy for the patient/parent/guardian, document missed visits and substitutes, and submit required forms (HCFA-485, HCFA-486, Form 166, and EPSDT Referral Form 167) for authorization and recertification.

• Service logs must show date and time of all services, signed by the nurse and caregiver, with a copy retained by the patient/parent/guardian.
• Document missed visits and implement substitute nurse policies; substitutes must complete and sign the service log after duties.
• Submit HCFA-485, HCFA-486, Private Duty Nursing Agreement for Care (Form 166), and EPSDT Referral for Services (Form 167) for authorization; submit HCFA-485/486 at least 14 days prior to recertification due date for continued services.

Recoupment risk for failure to follow EPSDT manual procedures

Failure to follow procedures and requirements in the EPSDT manual may result in recoupment of funds paid to the provider.

• Noncompliance with EPSDT manual procedures/requirements is subject to recoupment actions.

Recoupment risk for failure to meet required procedures/tests and documentation

Failure to meet required procedures/tests and documentation as specified in the Screening Provider Manual may result in recoupment of funds paid to the provider.

• All procedures/tests must be recorded; omission or lack of documentation can trigger recoupment following review.

Medicaid may discontinue/recoup payment if screening not performed, referral unrelated, or form invalid

Medicaid may discontinue and/or recoup payment if an EPSDT screening was not performed, the diagnosis on the referral does not relate to the treatment performed, or the EPSDT screening form is not valid (screening referral forms are valid only for the time specified by the referring provider or up to a maximum of 12 months).

• Ensure an EPSDT screening was performed before billing for referred services.
• Ensure the referral diagnosis relates to the treatment performed.
• Confirm the EPSDT screening referral form is valid (time specified by referring provider or ≤ 12 months).