CurrentNew Mexico Health Care AuthorityPolicy N/A

EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES

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Defines Early and Periodic Screening, Diagnostic and Treatment (EPSDT) supplemental services for MAP-eligible recipients under 21 including special rehabilitation, case management, personal care services (PCS), and private duty nursing (PDN); describes provider eligibility, service definitions, coverage criteria, treatment plan and utilization controls.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyEARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionObtain prior authorization from MAD or its designee for therapy services (except the initial evaluation) and for PDN or when special rehabilitation exceeds 14 hours/month.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 hrs/mospecial rehab prior-approval threshold

40 hrsPCS attendant training (1st year)

62 daysRN supervisory visit frequency

Under 21

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CurrentNew Mexico Health Care AuthorityPolicy N/A

EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyEARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionObtain prior authorization from MAD or its designee for therapy services (except the initial evaluation) and for PDN or when special rehabilitation exceeds 14 hours/month.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 hrs/mospecial rehab prior-approval threshold

40 hrsPCS attendant training (1st year)

62 daysRN supervisory visit frequency

Under 21

initial evaltherapy prior auth exception

EPSDT Coverage Criteria

Special rehabilitation (developmental eval, nursing, PT, OT, SLP, behavioral health)

Special rehabilitation services covered when provided as part of FIT and following referral from PCP

Special rehabilitation general criteria: Services involve the MAP eligible recipient's family, support and enhance developmental services, and are provided through FIT; covered services include developmental evaluation and rehabilitation, nursing, physical therapy, occupational therapy, speech/language/hearing services, and behavioral health; services result from a referral from the MAP eligible recipient's PCP and are provided by MAD-enrolled qualified providers.

Includes diagnostic, evaluative, consultative services and family consultation; subject to existing MAD limitations and prior approval rules (see utilization thresholds).

EPSDT case management

Case management covered when ALL of the following are met

Case management eligibility and delivery: Recipient is MAP enrolled and under 21 and determined medically at risk; services are furnished by a qualified MAD-enrolled case management agency and by case managers who meet required qualifications (minimum one year experience serving medically at risk under-21 individuals or hold a specified bachelor's degree, or be licensed RN/LPN; medically fragile recipients require RN case manager); a CMTP must be developed within 30 calendar days (an ISP for medically fragile recipients must be written and approved within 60 calendar days) and updated annually or as indicated; face-to-face assessments are performed and documentation (CMTP/ISP and supporting assessments) must be available in the recipient's file.

Agency must demonstrate direct experience and knowledge of community resources; agency types enumerated (governmental, tribal, IHS, FQHC, community case management agency).

EPSDT personal care services (PCS)

PCS covered when ALL of the following are met

PCS coverage criteria: Recipient is a MAP eligible recipient under 21 with a need for assistance with two or more ADLs or IADLs; PCS services are medically necessary, prescribed/ordered by the recipient's PCP and included in the recipient's individualized treatment plan (ITP/IEP/IFSP); need is evaluated based on availability of family and natural supports; consent is obtained from parent/guardian or recipient as applicable; services furnished in the recipient's residence and, when medically necessary and not available through other benefits, in school; provided by trained PCS attendants employed by a MAD-approved PCS agency under direct supervision of a MAD-approved RN.>= 2 ADLs/IADLs

PCS ITP must be approved by MAD or its designee prior to initiation; supervisory RN visits to assess recipient progress and attendant performance documented every 62 calendar days (or more often if warranted); ITP reviewed at least every six months.

EPSDT private duty nursing (PDN)

PDN covered when ALL of the following are met

PDN coverage criteria: Recipient is a MAP eligible recipient under 21 who requires more continuous individual skilled nursing care than available through the MAD home health program; PDN services are ordered by the recipient's PCP, included in an approved ITP/ISP, medically necessary, and within the scope of the nursing profession; services furnished by an RN or LPN in the recipient's home or in the school setting when medically necessary for school attendance; recipient must have an approved ISP before nursing services begin and prior authorization is required.

PDN agencies must be MAD-approved; PDN services subject to general MAD limitations and coverage restrictions; ISP meeting must be held and ISP written/approved before services start.

EPSDT PDN and Rehabilitation Coverage Criteria

Covered when ALL of the following are met

Age: Recipient is a MAP eligible recipient under 21 years of age for EPSDT rehabilitation and PDN services.<21 years

Applies to rehabilitation, PCS, case management and PDN services.

Medical necessity: Services are medically necessary and provided for diagnostic study or treatment to improve, restore or maintain the recipient's condition, control symptoms, or prevent further deterioration as documented in the individualized treatment plan (ITP/ISP).medical necessity documented in treatment plan

Applies to PT/OT/SLP and nursing services.

Treatment plan and authorization: Services are specifically related to an active written treatment plan developed by a qualified PT, OT, or SLP (or RN for PDN) and authorized by the recipient's PCP; all therapy services except the initial evaluation require prior authorization from MAD or its designee.

Certain EPSDT services are subject to specific billing limitations. Case management services may not be billed for individuals who are not MAP eligible or who do not meet MAD's definition of medically at risk, nor may case management be billed for recipients who receive case management through a home and community‑based services waiver. Case management must not be billed for activities provided by other practitioners (for example, therapists, transportation providers, homemakers or personal care service providers), for formal educational or vocational instruction, for client outreach or routine administrative activities (such as MAD eligibility determinations and agency intake processing), or for institutional discharge planning when that planning is included in payment for inpatient or residential services. In addition, case management services must be documented in the MAP eligible recipient's agency file; undocumented activities are noncovered.

MAD does not cover services that are related solely to the recipient's general good and welfare rather than to a medically necessary treatment goal. Examples include general exercise programs intended only to promote overall fitness or flexibility and activities provided merely to increase motivation. Similarly, PCS may not be billed for tasks requiring professional or technical training (for example, catheter insertion/irrigation, tube feedings, nebulizer treatments, sterile dressings involving prescription medications, irrigation of body cavities, performance of bowel stimulation, or medication administration). Services not included in the recipient's approved ITP or lacking prior approval, and services not determined to be medically necessary by MAD or its designee, are also noncovered.

PCS services that are determined by MAD or its designee to be not medically necessary for the MAP eligible recipient's condition are noncovered and must not be billed to MAD.

Activities performed solely for the recipient's general good and welfare are not considered physical or occupational therapy for MAD reimbursement and are noncovered. Examples include general fitness or flexibility exercises and motivational activities that are not tied to an active treatment plan or specific therapeutic goals.

Provider Types and Coding Notes

Provider types eligible for reimbursementmixed

No codes listed

Special rehabilitation prior approval threshold

Prior approval thresholdMore than 14 hours per month of special rehabilitation services requires prior approval from DOH.

Applies toMAD EPSDT special rehabilitation services (developmental evaluation, nursing, PT/OT/SLP, behavioral health).

Review basisUtilization review for medical necessity and program compliance; reviews may occur before or after services or payment.

PCS attendant training hours

Minimum training — first yearNo less than 40 hours of training to be completed by the PCS attendant in the first year of employment.

Pre-placement requirementTen hours of training must be completed prior to placing the employee in a MAP eligible recipient's home (two of these may be agency orientation; eight must be recipient-specific).

Prior Authorization, Documentation & Billing Rules

Prior Authorization

Prior approval and PDN authorization required

Prior approval is required when special rehabilitation services exceed 14 hours per month; PDN services require prior authorization and an approved ISP before services may begin.

Special rehabilitation: a maximum of 14 hours per month can be furnished before prior approval is required.
PDN: nursing services require an approved ISP and prior authorization prior to initiation.

Prior Authorization

Therapy prior authorization (except initial eval)

All therapy services except the initial evaluation require prior authorization from MAD or its designee.

Initial evaluation is exempt from prior authorization; subsequent therapy visits require authorization.
Therapy must be related to an active written treatment plan and authorized by the recipient's PCP.

Policy Background

The purpose of EPSDT supplemental services is to identify and treat health conditions that affect MAP eligible recipients under 21 and to support their development and functional abilities so they can remain in the least restrictive setting. Services under EPSDT — including special rehabilitation (developmental evaluation, nursing, physical, occupational and speech therapy, and behavioral health), case management, personal care services, and private duty nursing — are intended to diagnose and treat conditions, help recipients retain or achieve maximum independence, mobilize natural supports, coordinate and monitor service delivery, and revise the recipient's treatment plan or ISP as needed. Many enhanced services (for example, private duty nursing) must be included in the CMTP or ISP to be furnished and require the specific documentation elements and approvals described in the rule.

Key Definitions

Medically at risk / Medically fragile

Definition'Medically at risk' is an individual with a diagnosed physical or social emotional condition that has a high probability of impairing cognitive, emotional, neurological, social or physical development.

Use for eligibilityRecipients determined 'medically at risk' are eligible for case management services under EPSDT.

Related term'Medically fragile' criteria apply for PDN shift care and parameters approved by MAD (see PDN coverage requirements).

Personal Care Services (PCS) definition

DefinitionPersonal Care Services (PCS) are medically necessary assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) for MAP eligible recipients under 21 as part of EPSDT when included in the recipient's IEP or IFSP.

Examples of ADLs/IADLs

Policy Summary

PayerNew Mexico Health Care Authority

PolicyEARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionObtain prior authorization from MAD or its designee for therapy services (except the initial evaluation) and for PDN or when special rehabilitation exceeds 14 hours/month.

SourceLink

On This Page

treatment plan + prior authorization (except initial therapy evaluation)

PCP must be a physician, DO, certified nurse practitioner, or physician assistant licensed in New Mexico.

Provider qualifications: Rehabilitation services furnished by or under supervision of appropriately licensed PT, OT, or master's-level SLP, and PDN furnished by RN or LPN; eligible provider types include certified outpatient rehab centers, home health agencies, licensed nursing agencies, FQHCs and other MAD-enrolled providers.licensed/supervised providers

Services must be performed within the scope of practice defined by state statute and practice boards.

PDN settings: PDN is covered when skilled nursing services are furnished to the recipient at home or in the school setting if medically necessary for school attendance; nursing services are furnished only to the MAP eligible recipient.home or school setting

School-based PDN is an alternative to homebound programs; services require ISP approval and prior authorization before initiation.

Training topics (minimum)Includes communication, recipient rights, recordkeeping, nutrition/meal preparation, care of ill and disabled children/adolescents.

Step Therapy

PCS must follow utilization sequencing and approval

PCS may only be furnished after approval by MAD or its designee's utilization review (UR) contractor and only when services are not available through other benefits.

PCS must not be provided in lieu of available services from home health, early intervention, or school programs when those benefits apply.
The PCS ITP must be approved by MAD or its designated UR contractor prior to initiation of PCS services.

Note

Placeholder (no additional requirement specified)

No specific entry — reserved placeholder to preserve source chunk indexing for fallback.

Documentation Required

Required CMTP / ISP development and availability

Develop and maintain a Case Management Treatment Plan (CMTP) within 30 calendar days of service initiation (or an ISP within 60 days for medically fragile recipients); the CMTP/ISP and all supporting documentation must be available in the recipient's file and updated annually or as indicated.

CMTP/ISP must include problem statement, comprehensive functional assessments, least restrictive conditions, intermediate and long-range goals with timetables, service frequency/intensity, and provisions for review/modification and discontinuation.
Assessments must be performed face-to-face and documented in the recipient's agency file.

Documentation Required

PCS attendant training and competency documentation

PCS attendants must complete a training program and have documented competency: at least 40 hours of training in the first year with 10 hours completed prior to placement (two of the 10 may be agency orientation; eight of the 10 must be specific to the recipient).

Training curriculum must include communication, recipient rights, recordkeeping, nutrition/meal preparation, care of ill and disabled children/adolescents, emergency response (first aid, CPR, 911), basic infection control, housekeeping skills, and home safety/fire protection.
The PCS agency is responsible for ensuring competency for assigned tasks specific to the recipient's needs.

Documentation Required

Required PDN plan elements and ISP approval

PDN requires an approved treatment plan/ISP that contains a physical assessment, psychosocial evaluation, medication history, applicable clinical interventions with measurable goals, specification of nursing responsibilities and orders, and a transition plan; the ISP must be approved before nursing services can begin.

Plan elements must identify durable medical equipment/supplies needed, level of family support, medication compliance, intermediate and long-range goals with timetables, nursing care plan and rationale, and orders for medications/treatments/therapies.
The ISP meeting must be held and the ISP written and approved by the RN or case manager prior to initiation of PDN services.

Documentation Required

Therapy written treatment plan and authorization

Therapy services must be supported by an active written treatment plan developed by a qualified PT, OT, or SLP and authorized by the recipient's PCP; services must be performed within scope of licensure and prescribed/ordered by the PCP.

PCP must be a physician, doctor of osteopathy, certified nurse practitioner, or physician assistant licensed in New Mexico.
All therapy services except the initial evaluation require prior authorization from MAD or its designee.

Denial Risk

Case management denial triggers — eligibility and documentation

Do not bill for case management if the recipient is not MAP-eligible, does not meet the MAD definition of 'medically at risk', receives case management through an HCBS waiver, or when services are not documented in the recipient's agency file.

Case management services billed for services furnished by other practitioners (therapists, transportation providers, homemakers) are noncovered.
Ensure all case management activities are documented in the recipient's file to avoid denial.

Denial Risk

PCS denial triggers — licensed tasks and ITP/medical necessity

PCS services may be denied if they require tasks that must be provided by licensed or technical personnel (for example: catheter insertion/irrigation, nebulizer treatments, tube feedings, sterile dressings with prescription meds, bowel stimulation) or if services are not in an approved ITP or lack prior approval or medical necessity.

Confirm tasks requested fall within PCS attendant scope and are documented in the approved ITP prior to billing.
Services not considered medically necessary by MAD or its designee are noncovered.

Denial Risk

PDN denial triggers — prior authorization and ISP required

PDN requires prior authorization and an approved ISP before nursing services can begin; absence of prior authorization or an approved ISP will trigger denial of PDN claims.

PDN services must be ordered by the PCP and included in the recipient's approved treatment plan.
Agencies must be MAD-approved PDN agencies and services must be within the scope of nursing.

Denial Risk

Ongoing therapy requires prior authorization — risk of denial

Therapy services (except initial evaluation) require prior authorization from MAD or its designee; failure to obtain required authorization may result in claim denial or repayment.

Ensure ongoing therapy sessions are authorized before delivery and billing.
Initial evaluations do not require prior authorization but must still be supported by a treatment plan for subsequent services.

Denial Risk

PDN subject to general MAD coverage limitations

PDN services are subject to the general MAD limitations and coverage restrictions that apply to other EPSDT services; services outside those restrictions risk denial.

MAD does not cover services related to general good and welfare (e.g., general fitness exercises) and PDN is subject to general noncovered service rules.
Confirm PDN care meets medical necessity and program limitations prior to initiation.

Bathing, dressing, grooming, eating, toileting, shopping, transporting, care of assistance animals, cognitive assistance and communication; may include cuing/supervision for cognitive impairments.

Setting and provisionProvided in the recipient's residence or, when medically necessary, in school; furnished only by trained PCS attendants employed by MAD-approved agencies under RN supervision and included in the ITP/IEP/IFSP.

EPSDT rehabilitation services

DefinitionEPSDT rehabilitation services are medically necessary outpatient services furnished to MAP eligible recipients under 21 by or under the supervision of licensed physical therapists (PT), occupational therapists (OT), and master's-level speech-language pathologists (SLP).

PurposeServices are rehabilitative, active or restorative, designed to correct or compensate for medical problems interfering with age-appropriate functional performance, and include evaluation and family consultation.

AuthorizationServices must be related to an active written treatment plan developed by a qualified therapist and authorized by the recipient's PCP; ongoing therapy (except initial evaluation) requires prior authorization.

PDN covered services definition

DefinitionPrivate Duty Nursing (PDN) are skilled nursing services furnished to the MAP eligible recipient at home or, when medically necessary, in the school setting as an alternative to homebound programs.

ScopeServices include skilled nursing care specific to the recipient; nursing services are furnished only to the MAP eligible recipient and not to others in the school setting.

Documentation and authorizationPDN requires an approved ISP/treatment plan containing nursing care plan, nursing responsibilities, medication orders, and a transition plan; prior authorization is required before services begin.