CurrentUnitedHealthcarePolicy N/A

EPSDT Medical Necessity Form

A standardized request form and guidance for clinicians to submit medical necessity requests under EPSDT for Medicaid recipients under age 21 to request coverage of services/products/procedures that are non-covered under the state plan. It collects recipient, provider, clinical history, treatment rationale, safety/effectiveness, alternatives, and signature.

Policy Summary

PayerUnitedHealthcare

PolicyEPSDT Medical Necessity Form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must complete the form fields (recipient, provider, CPT/HCPCS codes, clinical history, diagnoses, treatments, rationale, safety/effectiveness, alternatives, expected duration) and submit supporting records to establish medical necessity for recipients under 21.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes documented for this policy.

1Form Pages (document)

Under 21Applicable Population

EPSDT Medical Necessity Form — Summary

This is a standardized request form and guidance for clinicians to submit medical necessity requests under EPSDT for Medicaid recipients under age 21 to request coverage of services, products, or procedures that are not covered under the state plan. It collects recipient and provider identifying information, CPT/HCPCS codes when applicable, clinical history and diagnoses, prior and current treatments, a rationale describing how the requested service will improve or maintain health, statements about safety and whether the request is experimental, alternatives and evidence if available, expected duration of treatment, and the requestor's signature and credentials.

Policy Summary

PayerUnitedHealthcare

PolicyEPSDT Medical Necessity Form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

SourceLink

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EPSDT Submission Criteria (Medical Necessity Requirements)

EPSDT Medical Necessity Submission Criteria

Complete all requested information and submit supporting records to aid determination of medical necessity for recipients under 21:

ALL of the following

Recipient information completed by physician, licensed clinician or other provider (name, DOB, Medicaid ID, address).
Provider/requestor information completed including NPI, addresses, telephone, fax.
Requested procedure/product/service identified and CPT/HCPCS code(s) if applicable.
Treating capacity: Statement of treating capacity (how long treated and nature of care).
Health history: Recipient health history including chronic illnesses.
Diagnoses: Recent diagnosis(es) related to request with onset, course and current status.
Prior/current treatments: Description of previous and current treatments, duration, goals, and response.
Detailed rationale of benefit: Detailed description of how the requested service will correct or ameliorate the recipient's defect, illness, or condition and how it will improve/maintain health, compensate, prevent worsening or prevent additional health problems.
Experimental status: Indication whether request is experimental/investigational (Yes/No).
Safety: Indication whether the requested product/service/procedure is considered safe (Yes/No).
Effectiveness per Kan. Admin. Regs.: Indication whether it is effective (Yes/No) per Kan. Admin. Regs. § 129-1-1 definition (intervention reasonably expected to produce intended results and benefits outweigh harms; consider scientific evidence, professional standards, expert opinion).
Refer to Kan. Admin. Regs. § 129-1-1 for definition and evidentiary hierarchy.
Alternatives & evidence: Identify alternative treatments that are more cost-effective but similarly effective, if any, and provide evidence if available.
Expected duration of treatment.
Signature: Requestor's signature and credentials and date.

Actions Required by Providers

Documentation Required

Complete EPSDT Medical Necessity Form

Providers must complete all required form fields and submit supporting records to establish medical necessity for recipients under 21.

Recipient (name, DOB, Medicaid ID, address)
Provider/requestor (name, NPI, addresses, telephone, fax)
Requested procedure/product/service and CPT/HCPCS code(s)
Clinical history and treating capacity (duration and nature of care)
Recent diagnoses (onset, course, current status)
Previous and current treatments, duration, goals, response
Rationale: how the requested service will improve/maintain health
Safety and effectiveness indications (Yes/No)
Alternatives (more cost-effective but similarly effective) and evidence
Expected duration of treatment
Requestor's signature, credentials and date

Prior Authorization

Submit for Non-Covered State Plan Services

Use this form to request coverage of services, products, or procedures not covered by the state plan for Medicaid recipients under 21. Submit the completed form and supporting records to the appropriate prior authorization phone or fax number for the recipient's plan.

See 'Administrative Contact Phone/Fax Numbers by Plan' for the plan-specific PA phone/fax to use.

Documentation Required

Attest Safety/Effectiveness and Experimental Status

Providers must indicate whether the request is experimental/investigational and attest whether the product/service/procedure is safe and effective per Kan. Admin. Regs. § 129-1-1.

Documentation Required

Provide Alternatives and Evidence

If there are alternatives that are more cost-effective but similarly medically effective, providers must list those alternatives and attach the supporting evidence base with the request, if available.

Requested Codes and Administrative Contact Numbers

Requested Procedure Codes (to be provided by submitter)CPT/HCPCS

No codes listed

Administrative Contact Phone/Fax Numbers by Planmixed

Kansas_PA_Phone	Kansas Medical Assistance Program PA Phone 800-933-6593
Kansas_PA_Fax	Kansas Medical Assistance Program PA Fax 800-913-2229
HealthyBlue_PA_Phone	Healthy Blue PA Medical Phone 833-405-9086
HealthyBlue_PA_Fax	Healthy Blue PA Medical Fax 800-964-3627
HealthyBlue_Pharmacy_Phone	PA Pharmacy Phone 833-838-2595
HealthyBlue_Pharmacy_Fax	PA Pharmacy Fax 877-941-9901
Sunflower_PA_Phone	Sunflower PA Medical Phone 877-644-4623
Sunflower_PA_Fax	Sunflower PA Medical Fax 888-453-4316
Sunflower_Pharmacy_Phone	Sunflower PA Pharmacy Phone 877-397-9526
Sunflower_Pharmacy_Fax	Sunflower PA Pharmacy Fax 833-645-2740

Definitions & Regulatory Reference

Definition: Per Kan. Admin. Regs. § 129-1-1, "Effective" means that the intervention can be reasonably expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

Medical necessity determinations should, to the greatest extent possible, be based first on the scientific evidence for each existing intervention; if no scientific evidence is available, then professional standards of care should be considered; if those do not exist, are outdated, or are contradictory, decisions should be based on expert opinion. Coverage should not be denied solely because conclusive scientific evidence is absent; interventions may meet the regulation's definition of medical necessity in the absence of scientific evidence if there is a strong consensus of effectiveness in up-to-date and consistent professional standards of care or, absent those, convincing expert opinion.