EPSDT and YSHCN review
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This administrative guideline governs prior authorization review for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and Youth with Special Health Care Needs (YSHCN) members, specifying approval length and basic eligibility criteria for CareOregon members.
No material clinical or coverage changes in this revision.
Approval Criteria
inv-01: Approval Criteria
Approval Criteria (all of the following)
ALL of the following
ONE of
- Member is less than 21 years old
- Member has EPSDT benefits under YSHCN (certain members age 21-25)
EPSDT and YSHCN Prior Authorization Guideline — Provider Actions
EPSDT and YSHCN prior authorization — 12‑month approval; member eligibility requirements
Prior authorization for EPSDT and YSHCN reviews is an administrative guideline with approvals granted for up to 12 months. Providers must request prior authorization only for members who meet the approval criteria: the member is less than 21 years old, or the member has EPSDT benefits under YSHCN (certain members age 21–25).
- Approval length: 12 month(s).
- Eligibility for PA review: member <21 years old, OR member has EPSDT benefits under YSHCN (certain members age 21–25).
- Submit PA requests in accordance with CareOregon prior authorization processes and include documentation demonstrating member eligibility under the criteria above.
Definitions and Key Details
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