CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

EPSDT well visits and immunizations

Affirms that EPSDT services, including well-child visits and immunizations per CDC/AAP schedule, are required and funded in part by the State of New Mexico; applies to BCBSNM members, pediatric providers, and administrative staff.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT well visits and immunizations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure immunizations follow the CDC Child and Adolescent Vaccine Schedule and offer them at all visits, including sick visits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1document pages/chunks provided

CDC/AAPreferenced immunization schedule sources

1-866-689-1523auxiliary aids contact number

Coverage criteria for EPSDT well-child visits and immunizations

EPSDT well visits and immunizations

Covered as EPSDT services

EPSDT requirement: Well visits (EPSDTs) and immunizations per CDC/AAP schedule are required and should be offered at all visits, including sick visits.

Document reproduces AAP periodicity schedule; services funded in part by State of New Mexico.

No explicit exclusions are listed in the provided content.

No "not medically necessary" statements are present in the provided text.

Coding and numeric thresholds

No codes listedmixed

No codes listed

No numeric thresholds or limits

Numeric thresholds or limitsNone specified — the policy contains no numeric thresholds, limits, or measurable numeric criteria for EPSDT services or immunizations.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT well visits and immunizations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure immunizations follow the CDC Child and Adolescent Vaccine Schedule and offer them at all visits, including sick visits.

SourceLink

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Provider responsibilities and required actions

Note

EPSDT immunizations requirement — Immunizations and well visits are required under EPSDT

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requires that well visits and immunizations be offered and provided to eligible members. Immunizations should be offered at all visits, including sick visits, and providers must use the CDC Child and Adolescent Vaccine Schedule to ensure immunizations are up to date.

EPSDT requires immunizations and well visits be offered/provided
Offer immunizations at all visits, including sick visits
Use CDC Child and Adolescent Vaccine Schedule to verify immunization status

Documentation Required

PROVIDER ACTIONS — provider-facing actionable requirements

Providers must screen immunization status at every encounter and document offers/administration in the medical record. When immunizations are not administered, document the clinical reason or parental declination. Ensure vaccine administration is billed using the appropriate CPT/HCPCS codes and include necessary documentation in the chart.

Screen immunization status at every encounter and document in the record
If not administered, document clinical reason or parental declination
Bill using appropriate vaccine administration codes and retain documentation

Note

PROVIDER ACTIONS — Providers should ensure immunizations are up to date with CDC schedule and offer immunizations at visits

Ensure immunizations are current per the CDC Child and Adolescent Vaccine Schedule; offer and administer needed vaccines during well-child visits and sick visits whenever clinically appropriate. Verify prior immunization records, update the state immunization registry as required, and provide anticipatory guidance to caregivers about upcoming vaccines.

Follow CDC Child and Adolescent Vaccine Schedule
Offer/administer needed vaccines at well and sick visits when appropriate
Verify records and update state immunization registry

Denial Risk

PROVIDER ACTIONS — No explicit denial triggers stated; emphasize offer-at-all-visits guidance

There are no explicit denial triggers listed for not administering vaccines; however, failure to offer vaccines or failure to document offers, medical contraindications, or parental refusal may increase denial risk for preventive services. Always offer vaccines at each visit and document offers, refusals, contraindications, or clinical deferrals to mitigate potential claim denials.

No explicit denial triggers stated in policy text
Failure to offer or to document offers/refusals/contraindications may increase denial risk
Document offers, refusals, contraindications, or clinical deferrals to reduce denial risk

Background on EPSDT and scope

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) encompasses preventive pediatric care and requires that well-child visits (EPSDTs) include review and provision of recommended immunizations. The policy reiterates that immunizations should be offered at all visits, including sick visits, and that providers should follow the CDC Child and Adolescent Vaccine Schedule and the American Academy of Pediatrics periodicity guidance; these services are funded in part by the State of New Mexico. For auxiliary aids or materials in other formats, call 1-866-689-1523.

Key definitions

EPSDT (Early and Periodic Screening, Diagnostic and Treatment)

DefinitionEarly and Periodic Screening, Diagnostic and Treatment (EPSDT) — a federally required Medicaid benefit that includes well-child visits, screenings, diagnostic services, treatment when needed, and immunizations as part of preventive pediatric care.

Scope of servicesIncludes well visits (EPSDTs) and immunizations; the policy emphasizes offering immunizations at all visits, including sick visits.

Guiding schedulesReferences the CDC Child and Adolescent Vaccine Schedule and the American Academy of Pediatrics periodicity schedule for recommended ages and procedures.

Funding/AuthoritySuch services are funded in part with the State of New Mexico; BCBSNM has reproduced the AAP periodicity schedule with permission.

Access supportsAuxiliary aids and services or materials in other formats and languages are available at no cost via the provided contact number (1-866-689-1523).