What is Early and Periodic Screening, Diagnostic and Treatment (EPSDT)?
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a federal law which requires Medicaid to pay for periodic screening, vision, dental and hearing services for children under 21 years of age. The services must be medically necessary to correct or treat a defect, physical or mental illness or a condition diagnosed by the child’s physician, therapist or other licensed provider.
Early: Assessing and identifying problems early.
Periodic: Checking children’s health at age-appropriate intervals.
Screening: Providing physical, mental, developmental, dental, hearing, vision and other screening tests to detect potential problems.
Diagnostic: Performing diagnostic tests to follow up when a health risk is identified.
Treatment: Correct, reduce or control health problems found.
Who qualifies for EPSDT?
Children and Youth under age 21 who are enrolled in Medicaid qualify to receive EPSDT services.
What are EPSDT criteria?
- The service must be within the scope of those listed in the Social Security Act (42 U.S.C. 1396d(a)).
- The service must be medically necessary to correct or improve a defect, physical or mental illness, or a condition [health problem] diagnosed by the recipient’s physician, therapist or other licensed practitioner.
- The requested service must be a medical service.
- The service must be safe.
- The service must be effective.
- The service must be generally recognized as an accepted method of medical practice or treatment.
- The service must not be experimental or investigational.
Additionally, services can only be covered if they are provided by a North Carolina Medicaid enrolled provider for the specific service type. This may include an out-of-state provider who is willing to enroll if an in-state provider is not available.
If you have questions about EPSDT services, talk with your child’s PCP or provider.
Visit the NC Medicaid EPSDT webpage for more information about the Federal EPSDT guarantee.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
- Explores EPSDT requirements, periodicity schedules, diagnostic/treatment components and service coordination.
- Focuses on oral health services for Medicaid-insured children.
The assigned primary care provider (PCP) is responsible for EPSDT services, including screening, diagnosis and treatment. Screening services include:
- Routine physical examinations as recommended and updated by the American Academy of Pediatrics (AAP) “Guidelines for Health Supervision III” and described in “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.”
- Screening for developmental delay at each visit through the 5th year.
- Screening for Autism Spectrum Disorders per AAP guidelines.
- Health and development history.
- Physical exam.
- Development assessment and behavioral health screening.
- Inpatient psychiatric care for individuals under age 21.
- Rehabilitative services for intellectual/developmental disabilities (I/DD).
- Mental health and substance use disorder services.
- No limit on number of visits to therapist.
- Delivery of research-based intensive behavioral health treatments (RBI-BHT).
- Assessment and provision of immunizations as appropriate for age and health history, in accordance with the schedule for pediatric vaccines.
- Assessment of nutrition status.
- Vision testing.
- Hearing testing.
- Laboratory procedures appropriate for age and population groups, including blood lead screening.
- Oral testing.
- Infant members under the age of 1 must be referred to a dentist or dental professional working under the supervision of a dentist as part of the Medicaid Fee-for-Service program.
- Health education.
- Referral for additional services if indicated for further diagnosis and treatment.
Non-Covered State Plan Services for Under 21 Prior Approval Request Form
Where do I get EPSDT services?
- You can get these services from providers in the Partners network or from another Medicaid provider. Prior authorization is not required for preventive screening services under EPSDT but may be required for diagnostic and treatment services. If prior approval is required, and if the member does not meet the clinical coverage criteria or needs more than the clinical coverage policy limits, the provider should submit documentation with the prior approval request that shows how the service at the requested amount and rate is medically necessary and meets all EPSDT criteria, including to correct or improve a physical or mental illness or health condition. If you have any questions, talk to your PCP or call Member Services at 1-888-235-4673; Relay NC 711 or TTY (English) 1-800-735-2962; (Spanish) 1-888- 825-6570.
What happens if Partners does not offer a service covered by the Federal Medicaid Program?
- Sometimes children need medical treatment for a behavioral health problem. Partners might not offer every service covered by the Federal Medicaid program. When a child needs treatment, we will pay for any behavioral health service that the federal government’s Medicaid plan covers. The proposed treatment must be evaluated on its ability to treat, fix or improve your child’s behavioral health problem or condition. This decision is made specifically for your child.
What rules apply when Partners approves a service?
- There are no copays for Medicaid-covered services to members under age 21.
- There are no limits on how often a service or treatment is given.
- There is no limit on how many services the member can get on the same day.
- Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.