CurrentDenver-Health-Medical-PlanPolicy N/A

EPSDT (Early and Periodic Screening, Diagnostic and Treatment) Coverage Criteria

Defines EPSDT program benefits, wrap-around services, care management, and resources for Denver Health Medicaid Choice members aged 20 and under and pregnant women. Affects Denver Health providers delivering preventive, diagnostic, and treatment services under Health First Colorado/Medicaid.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyEPSDT (Early and Periodic Screening, Diagnostic and Treatment) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument EPSDT screening components (health history, unclothed head-to-toe exam, development and mental/behavioral assessments, vision/hearing screening, immunizations, and age-appropriate labs) to support medical necessity and coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

members ≤20 + pregnantpopulation covered

PCP within 30 daystimely access expectation

12 monthspostpartum services duration

303-602-2184CM referral

EPSDT Coverage Criteria

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Comprehensive EPSDT Screening

Covered EPSDT services include the following screening components and related services when medically necessary:

EPSDT screening components: Health history; unclothed head-to-toe physical exam; identification of all medical conditions and needs; immunizations per ACIP schedule; age-appropriate laboratory tests (including lead toxicity testing); health education and anticipatory guidance; development assessment; mental/behavioral health assessment; vision screening; hearing screening; oral/dental screening; adolescent family planning and maternity care; referrals for needed services; follow Bright Futures/AAP periodicity schedule.

All items listed are part of the comprehensive EPSDT screening and support coverage when medically necessary.

Wrap-Around Benefits

Wrap-around services payable by the State when medically necessary and authorized:

Examples of wrap-around services: Hearing aids and auditory training; audiological assessment and hearing evaluation; dental/hygienist care and treatment; orthodontia for severe, handicapping malocclusions; transportation for non-emergency medical, dental, or behavioral/mental health care; hospice services; skilled nursing facility care; intestinal transplants; private duty nursing; pediatric behavioral therapies; doula services.

These services require State authorization to be payable as wrap-around benefits.

Services that are not authorized by the State's fiscal agent are not payable as wrap-around benefits through Medicaid. Wrap-Around Benefits are additional treatments or services that fall outside the Denver Health Medicaid Choice covered benefits but may be covered by Medicaid when medically necessary and authorized by the State's fiscal agent. Providers should therefore obtain and confirm State authorization before billing Medicaid for wrap-around services to avoid denial of payment.

Provider Requirements and Authorization

Prior Authorization

State authorization required for wrap-around services

State-authorized wrap-around services may be available when a service is medically necessary but not covered under Denver Health Medicaid Choice. Examples include hearing aids and associated audiology services, dental care and orthodontia for severe malocclusions, transportation for non-emergency care, hospice, skilled nursing facility care, intestinal transplants, private duty nursing, pediatric behavioral therapies, and doula services. Providers must obtain State authorization (prior approval) before billing wrap-around services to ensure payment by the State's fiscal agent.

Hearing aids, auditory training, audiological assessment/evaluation
Dental/hygienist care and treatment; Orthodontia for severe, handicapping malocclusions
Transportation for non-emergency medical, dental, behavioral/mental health care
Hospice services; Skilled nursing facility care; Intestinal transplants; Private duty nursing
Pediatric behavioral therapies; Doula services

Documentation Required

EPSDT screening documentation

Providers must document EPSDT screenings comprehensively in the medical record. Documentation should include health history, an unclothed head-to-toe physical exam, identification of medical conditions/needs, immunization status per ACIP, age‑appropriate labs (including lead testing), health education/anticipatory guidance, developmental assessment, and mental/behavioral health assessment. Also document vision and hearing screenings, oral/dental screening, adolescent family planning/maternity care when applicable, any referrals made, and adherence to Bright Futures/AA Pediatrics periodicity guidance.

Document health history and unclothed 'head to toe' physical exam
Record immunizations per ACIP and age-appropriate laboratory tests (including lead)
Include development and mental/behavioral health assessments, vision and hearing screenings, and oral/dental screening
Document health education/anticipatory guidance, referrals, and follow-up plans; reference Bright Futures and AAP periodicity schedule

Note

Provider operational actions

Providers should be aware of operational actions that may impact care delivery and authorizations: ensure primary care providers offer appointments within 30 days of member request, and coordinate referrals and documentation promptly to support State authorization for wrap-around services when indicated.

PCP appointment within 30 days of request for members/pregnant women
Coordinate referrals and submit documentation needed for State prior authorization of wrap-around services

Prior Authorization

Wrap-around authorization requirement

Services not covered by Denver Health Medicaid Choice may still be covered as Medicaid wrap-around benefits when medically necessary and properly authorized. Before providing or billing these services, obtain the required State authorization and keep documentation demonstrating medical necessity and authorization status in the member's medical record.

Wrap-around coverage is contingent on State authorization and medical necessity
Maintain documentation of authorization and medical necessity in the medical record prior to billing

Background

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program ensures access to preventive, diagnostic, and treatment services for Medicaid members aged 20 and under and for pregnant women. EPSDT emphasizes early detection and treatment through comprehensive periodic screening that includes health history, an unclothed head-to-toe physical exam, developmental and mental/behavioral assessments, vision and hearing screening, immunizations per recommended schedules, oral/dental screening, and referral for needed services.

EPSDT services are provided at no cost to eligible members and should follow established schedules such as Bright Futures and ACIP to guide timing of screenings, immunizations, and age-appropriate laboratory testing. The program’s purpose is to identify health problems early and ensure timely access to medically necessary treatment and follow-up.

Key Definitions

inv-11: EPSDT — definition of Early and Periodic Screening, Diagnostic and Treatment program

TermEarly and Periodic Screening, Diagnostic and Treatment (EPSDT)

DefinitionA Health First Colorado (Colorado Medicaid) program that covers prevention, diagnostic, and treatment services for members aged 20 and under and pregnant women

Program goalDetect health problems early and ensure children receive physical, mental, vision, hearing, and dental care; ensure pregnant women receive timely prenatal services

inv-12: Wrap-Around Benefits — definition for treatments/services not part of Denver Health Medicaid Choice but covered by Medicaid when authorized

TermWrap-Around Benefits

DefinitionAdditional treatments or services not part of the Denver Health Medicaid Choice covered benefits but covered by Medicaid when medically necessary

Payment/authorizationCovered only when authorized by and payable by the State's fiscal agent

Relationship to Denver Health Medicaid ChoiceServices outside the plan's covered benefit set may be payable as wrap-around benefits if authorized by the State

OpenPayer

EPSDT (Early and Periodic Screening, Diagnostic and Treatment) Coverage Criteria

EPSDT Coverage Criteria

Coding and Access Metrics

Provider Requirements and Authorization

Background

Key Definitions