CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

EPSDT preventive services schedule for children

Defines Early and Periodic Screening, Diagnostic and Treatment (EPSDT) recommended ages for procedures and instructs providers that well visits should be used to ensure immunizations are up to date; applies to Blue Cross and Blue Shield of New Mexico members (pediatric population).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT preventive services schedule for children

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse well visits (EPSDTs) to confirm a child’s immunizations follow the CDC Child and Adolescent Vaccine Schedule and offer immunizations at all visits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1table referenced

2auxiliary aid numbers

1external source

Coverage Criteria

The source excerpt does not list any explicit coverage exclusions for EPSDT services or immunizations. No procedures, vaccines, or situations are identified as excluded in the provided text; the document focuses on the recommended schedule and offering immunizations at visits rather than specifying exclusions.

There are no statements in the excerpt declaring services or immunizations to be not medically necessary. The policy text emphasizes that immunizations are necessary and should be offered at all visits and does not include any language denying medical necessity for EPSDT services.

Provider Actions and Requirements

Denial Risk

Denial Triggers and Documentation

No explicit denial triggers are stated in this policy excerpt. Providers should document clinical rationale and immunization status at EPSDT/well visits to support medical necessity where relevant.

Document immunizations and counseling at each EPSDT/well visit.
There are no listed prior authorization, step therapy, quantity limits, or specific denial conditions in the provided excerpt.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT preventive services schedule for children

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse well visits (EPSDTs) to confirm a child’s immunizations follow the CDC Child and Adolescent Vaccine Schedule and offer immunizations at all visits.

SourceLink

On This Page

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Note

Immunization Verification During Well Visits

Well visits (EPSDT) are the recommended opportunity to verify and update a child’s immunizations to align with the CDC Child and Adolescent Vaccine Schedule. Providers should offer immunizations at all visits, including sick visits, and record vaccine administration or refusal in the medical record.

Use EPSDT/well visit encounters to confirm immunizations are up to date.
Offer immunizations at all visit types (well and sick) and document administration or parental refusal.

Prior Authorization

Prior Authorization and Step Therapy

The excerpt does not list any prior authorization or step therapy requirements. When none are specified, follow standard Blue Cross Blue Shield - New Mexico rules and check payer portals or plan-specific documents for any member-specific PA or step edits before billing.

No prior authorization requirements are listed in this section.
No step therapy requirements are described in this section.
Confirm payer-specific rules via provider portal or member benefits when in doubt.

Definitions

EPSDT (definition and key facts)

DefinitionEarly and Periodic Screening, Diagnostic and Treatment (EPSDT) — a Medicaid benefit covering preventive and diagnostic pediatric services, including well-child visits and immunizations.

PurposeProvides recommended ages for pediatric procedures and ensures children’s immunizations follow the CDC Child and Adolescent Vaccine Schedule.

Key practice pointWell visits (EPSDTs) are the best time to confirm and offer immunizations; immunizations should be offered at all visits, including sick visits.

Source attributionPolicy reproduces the American Academy of Pediatrics periodicity schedule with permission; services funded in part by the State of New Mexico.

Member supportAuxiliary aids and language services are available at no cost via toll-free numbers (English and Spanish) and TTY: see policy contact numbers.

Background

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are presented as the mechanism for routine pediatric preventive care. The document references an AAP periodicity schedule for recommended ages and notes that well visits (EPSDTs) are the best time to confirm that a child’s immunizations are up to date with the CDC Child and Adolescent Vaccine Schedule; it also states that immunizations should be offered at all visits, including sick visits.