DCS Comprehensive Health Plan

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services

Statement/Purpose

The DCS Comprehensive Health Plan’s (DCS CHP) Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program provides required health care services that are available and accessible to members. All DCS CHP members are afforded the EPSDT benefit whether Medicaid eligible or not.

Definitions

Arizona Early Intervention Program (AzEIP): Arizona’s statewide interagency system of early services and supports for families of infants and toddlers, birth through two years of age, with disabilities or delays. AzEIP is established by Part C of the Individuals with Disabilities Education Act (IDEA), which provides eeligible children and their families access to services to enhance the capacity of families and caregivers to support the child’s development.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT): A comprehensive child health program of prevention, treatment, correction, and improvement of physical and behavioral health conditions for AHCCCS members under the age of 21, to ensure availability and accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health conditions for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services as specified in Federal Law 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and behavioral health illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

Commercial Oral Supplemental Nutrition: Nourishment available without a prescription that serves as sole caloric intake or additional caloric intake.

Enteral Nutrition: Liquid nourishment provided directly to the digestive tract of a member who cannot ingest an appropriate number of calories to maintain an acceptable nutritional status. Enteral nutrition is commonly provided by Jejunostomy Tube (J-Tube), Gastrostomy Tube (G-Tube) or Nasogastric N/G) Tube.

Metabolic Medical Food Formulas Or Medical Foods: Nutrition and specialized diets used to treat inherited metabolic disorders that are rare genetic conditions in which normal metabolic function is inhibited by a deficiency in a critical enzyme. Metabolic formula or modified low protein foods are produced or manufactured specifically for individuals with a qualifying metabolic disorder and are not generally used by individuals in the absence of a qualifying metabolic disorder. In order to avoid toxic effects, the treatment of the associated metabolic disorder depends on dietary restriction of foods containing the substances that cannot be metabolized by the member.

Total Parenteral Nutritional (TPN) Therapy: Nourishment provided through the venous system to members with severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients to maintain weight and strength appropriate for the individual’s general condition. Nutrients are provided through an indwelling catheter.

Policy

DCS CHP, in partnership with its contracted Managed Care Organization (MCO), covers comprehensive and preventative health care services through its EPSDT program in accordance with AHCCCS requirements.

The DCS CHP EPSDT program facilitates access to a continuum of care for members through assessment of health needs, primary prevention, early intervention, diagnosis, provision of medically necessary treatment services, and follow-up care or referral of physical and behavioral health conditions.

The purpose of EPSDT program is to ensure the availability and accessibility of health care resources, and assists members in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems conditions.

All members of DCS CHP are afforded the EPSDT benefit whether Medicaid eligible or not.

DCS CHP provides the resources and systems necessary in order to:

• Maintain a network of healthcare professionals who are informed about EPSDT standards and requirements, and sufficient in number for EPSDT service delivery to eligible members;

• Train staff who oversee and provide support to members on EPSDT program policies and requirements;

• Inform members and their caregivers that EPSDT screenings and services are recommended and available;

• Monitor service utilization to identify members and/or healthcare professionals who do not comply with the recommendations;

• Conduct outreach activities (e.g., through written reminders, telephone contacts, text messaging and email) to encourage caregivers to obtain EPSDT screenings and services for children, at age appropriate intervals;

• Work with external resources, such as Head Start and community health partners, to maximize EPSDT compliance among members;

• Educate participating healthcare professionals to document EPSDT visits in detail and report encounters to Mercy Care DCS CHP;

• Increase the participation rate of members receiving services through EPSDT programs.

Under EPSDT, federal law requires that Title XIX cover all Medicaid-covered services listed in 42 USC 1396d(a) for members under the age of 21 when medically necessary and cost effective, even when the services are not listed as covered services in the AHCCCS State Plan, AHCCCS statutes, rules, policies.

EPSDT Screening services are provided in accordance with the periodicity requirements of Title 42 of the Code of Federal Regulations (42 C.F.R. 441.58), which are captured in the AHCCCS EPSDT Periodicity Schedule and AHCCCS Dental Periodicity Schedule. The service intervals on the periodicity schedules represent minimum requirements and any service determined to be medically necessary shall be provided, regardless of interval.

The EPSDT Program focuses on the continuum of care, which begins with the assessment of health needs, the provision of preventative screening, the identification of needed services, the initiation of referrals to address these services, and the completion of medical treatment and appropriate subsequent follow up.

EPSDT includes, but is not limited to:

• Inpatient and outpatient hospital services;

• Laboratory and x-ray services as needed;

• Physician, nurse practitioner services, physician assistant, licensed nurse midwife and other qualified provider services;

• Medications;

• Medically necessary nutrition therapy;

• Dental services, with oral health screening by the Primary Care Provider (PCP) in addition to dental services by dental providers;

• Family planning services and supplies;

• Women’s preventative care services as applicable;

• Maternity services as applicable;

• Nutritional assessments by a PCP;

• Physical, occupational, speech, feeding therapies;

• Behavioral health services;

• Medical appliance, equipment and supplies;

• Orthotics;

• Prosthetic devices;

• Eyeglasses; and bifocals, including unlimited repairs and replacement of eyeglasses;

• Transportation for all medically necessary visits or services; and

• Diagnostic, screening, preventative, and rehabilitative services.

EPSDT services do not include services that are:

• Experimental;

• Solely cosmetic; or

• Not medically necessary and not cost effective in comparison to other interventions or treatments.

DCS CHP recognizes the importance of EPSDT services for the health and well-being of children and youth in out-of-home care. Children entering out-of-home care may have poor health or have had inadequate health care due to the circumstances of their entry into out-of-home care. The DCS CHP EPSDT Program is the cornerstone of services that address the health needs for these children.

EPSDT services provide comprehensive health care through:

• Primary prevention;

• Early intervention;

• Diagnosis;

• Medically necessary treatment; and

• Follow up care of physical and behavioral health conditions for all enrolled children and youth.

Limitations and exclusions, other than the requirement for medical necessity, do not apply to EPSDT services when those services fall within one of the 28 optional and mandatory categories of medical assistance as defined in the Medicaid Act. Services are covered even if they are not listed as covered services in the AHCCCS State Plan, or DCS CHP statutes, rules, or policies as long as the services are medically necessary and cost effective.

Providers are required to utilize the age specific AHCCCS approved EPSDT Clinical Sample Templates during each well child visit, including but not limited to blood lead testing, developmental screenings, BMI, behavioral health, substance use, STIs, adolescent suicide screening, and availability of family planning services and supplies. EPSDT Clinical Sample Templates are available on the AHCCCS website, www.azahcccs.gov, or an electronic equivalent that encompasses all the aspects of the original form to document services provided and compliance with AHCCCS standards.

DCS CHP’s EPSDT Program coordinates with external collateral agencies to accomplish the goals of the program. Coordinating care and services with collateral agencies ensures that health problems are diagnosed and treated early before they become more complex. Members are referred for support services and community-based resources to support good health outcomes including, but not limited to:

• Women, Infants and Children’s (WIC) supplemental nutrition program, which provides formula and support services for both young children and pregnant mothers;

• Head Start programs to ensure members receive appropriate EPSDT services to optimize health and development;

• Arizona Early Intervention Program (AzEIP), which identifies members 0-3 years of age with developmental disabilities and offers family education and support, and makes appropriate referrals for therapies such as physical, speech and occupational therapies to optimize health and development;

• Division of Developmental Disability (DDD), for those members with a diagnosed developmental disability;

• Arizona Long Term Care System (ALTCS) for members requiring long-term ongoing care because of a disabling illness/condition; and

• Child Find.

EPSDT visits are commonly known as well child/woman/man visits.

DCS CHP requires EPSDT visits to be all-inclusive and include the following:

• A comprehensive health and developmental history that includes growth evaluations, utilizing pediatric age and gender appropriate growth charts, and developmental screening 42 CFR 441.56(b)(1) which includes physical, nutritional, and behavioral health assessments.

• Developmental surveillance with anticipatory guidance is required with the PCP at every EPSDT visit utilizing the most updated developmental milestones.

  • • The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) regularly update and revise developmental milestones through the “Learn the Signs. Act Early.” program. Use of the most recent developmental milestones identify the behaviors that 75% or more of children can be expected to exhibit at a certain age based on data, developmental resources and clinician experience. These changes to the milestone framework assist the PCP in identifying children delayed and would indicate immediate referral if they do not meet the milestone.

• General development screening, utilizing an AHCCCS approved developmental screening tool, is required at the 9, 18 and 30 month EPSDT visits. Autism Spectrum Disorder (ASD) specific developmental screening is required at the 18 and 24-month EPSDT visits. Accepted tools are described in the CMS Core Measure, Developmental Screening in the First Three Years of Life (DEV) Measure Specifications, and shall be used for screening purposes.

  • Due to DCS CHP’s unique population, DCS CHP encourages its contracted MCO partner and providers to conduct and use age appropriate, AHCCCS approved, developmental screening tools at all age appropriate EPSDT visits.

  • The appropriate follow up or referral of any abnormal developmental screening is required.

  • PCPs who administer Developmental screening tools are required to be trained in the use and scoring of the tools as indicated by the -AAP- and provide proof of certification in the use of developmental screening tools in order to bill for screenings. All qualified medical professionals must provide proof of certification to the Council for Affordable Quality Healthcare (CAQH).

  • Copies of the completed developmental screening tools must be maintained in the member’s medical record and are to be submitted with the EPSDT claim for reimbursement.

  • The general developmental tools currently approved for use with EPSDT visits at 9 months, 18 months, and 30 months are those indicated in the CMS Core Measure “Developmental Screening in the first Three Years of Life” and include:

    • Ages and Stages Questionnaire - 3rd Edition (ASQ-3) -Birth to age 5;

    • Parents’ Evaluation of Developmental Status (PEDS) - Birth to age 8;

    • Parent’s Evaluation of Developmental Status - Developmental Milestones (PEDS:DM);Survey of Well-Being of Young Children (SWYC).

  • Autism Spectrum Disorder (ASD) specific developmental screening is required at the 18 and 24 month EPSDT.

  • Modified Checklist for Autism in Toddlers (M-CHAT) (used only as a screening tool by a primary care provider, for children between 16 and 30 months of age, to screen for autism when medically indicated). www.firstsigns.org.

  • Developmental screening tools may be billed separately using CPT-4 code 96110 with the appropriate EP modifier, to indicate screening was performed in addition to the preventative service. Developmental testing (CPT-4 code 961112) is not considered a screening tool and is not separately billable.

• Physical assessments including a comprehensive unclothed physical examination, inclusive of all the elements are required to address the physical development of children and youth of all ages. For the appropriately aged child/youth this includes:

  • Clinical breast exam; and

  • Pelvic exam (as necessary, based on best practice and current recommendations).

• Nutritional screening and assessment by the PCP to include evaluation of growth and developmental issues, identify underweight or overweight body mass index (BMI), need for supplementation or medical foods, counseling, and the appropriate referrals and interventions are covered. Nutrition referrals and services do not require prior authorization. Nutritional assessments by the PCP are a separately billable service by the PCP. Nutrition assessments by a registered dietitian are covered when ordered by the PCP. This includes members who are underweight and overweight. Initial and ongoing requests for commercial oral nutritional supplementation are required to be submitted for prior authorization, with supporting documentation from the member’s PCP, on the required AHCCCS approved form “Certificate of Medical Necessity for Commercial Oral Nutritional Supplements”, and meet medical necessity. The “Certificate of Medical Necessity for Commercial Oral Nutritional Supplements” must have been completed within three (3) months of the request.

• Nutritional Therapy is covered for EPSDT members who are on Enteral Nutrition, Total Parenteral Nutrition (TPN) Therapy, or oral basis when determined medically necessary to provide either complete daily dietary requirements, or to supplement a member’s daily nutritional and caloric intake.

  • Prior authorization is required for Commercial Oral Supplemental Nutrition unless the child is already receiving nutrition through Enteral Nutrition or TPN therapy with previous PA or on a temporary basis due to an emergent condition. If a member qualifies for nutritional therapy due to a medical condition, the following is covered:

    • Nutrition that may be provided by Arizona WIC.

    • Nutrition that is medically necessary but may be a WIC-exempt formula, is provided for the member through medical supply providers other than WIC and is covered by the health plan.

  • Medical necessity for Commercial Oral Nutritional Supplements is determined on an individual basis by the member’s PCP or specialty provider.

  • The PCP or specialist shall use AHCCCS Medical Policy Manual (AMPM) 430 – Attachment B – AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements , along with supporting documentation (dated within three months of the request) to submit to the health plan for prior authorization and indicate which criteria meets the medical necessity of providing commercial oral nutritional supplements. Initial and Ongoing authorizations are valid for a period of six months. Subsequent authorization requests require submission of a current physical assessment in the form of a clinical note or other supporting documentation that includes the members overall response to supplemental therapy and justification for continued supplement use.

  • Member’s receiving nutritional therapy are to be physically assessed by the PCP, specialty provider, or registered dietician at least annually for member adherence and tolerance to the nutritional supplementation. Documentation of adjustments are made based on the member’s weight loss/gain and documentation demonstrating encouragement and assistance weaning the member from the necessity of nutritional supplementation, when appropriate, should be maintained and submitted with prior authorization requests when applicable.

• Metabolic Medical foods are covered for members diagnosed with metabolic conditions identified on the Newborn screening Panel as outlined in AMPM Policy 310-GG, Nutritional Therapy, Metabolic Foods, and Total Parenteral Nutrition. Metabolic formula or modified low protein foods covered are those that are processed or formulated to be deficient in the nutrient(s) specific to the member’s metabolic condition; meet the member’s distinctive nutritional requirements; determined to be essential to sustain the member’s optimal growth within nationally recognized height/weight or BMI, and metabolic homeostasis; obtained under physician order; member’s medical and nutritional status shall be supervised by the member’s PCP, attending physician or appropriate specialist. Soy formula is covered only for members receiving Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and KidsCare members diagnosed with galactosemia and only until members are able to eat solid lactose-free foods, foods that are available in the grocery store or health food store are not covered as a metabolic food.

• Behavioral health screening and services needed to correct or ameliorate behavioral health illness and conditions discovered by the screening services are covered. The PCP may provide behavioral health services within their scope of practice as outlined in AMPM Policy 510 - Primary Care Providers. A PCP that elects to provide behavioral health services must complete an annual assessment of the child/youth’s behavioral health condition. American Indian/Alaska Native (AI/AN) members may receive behavioral health services through an Indian Health Service or tribally owned and/or operated 638 facility regardless of health plan enrollment or behavioral health assignment.

  • The following behavioral health screenings are separately billable and a copy must be maintained by the PCP in the member’s medical record:

    • Adolescent suicide and depression screenings utilizing a norm referenced validated tool specific to suicide and depression should be performed at annual EPSDT visits beginning at 10 years of age. Positive screening results must be referred for appropriate and timely behavioral health services.

    • Postpartum depression screening, utilizing a norm referenced validated tool, when applicable for the birthing parent, shall be performed during the 1, 2, 4, and 6 month EPSDT visits. A positive screening result must be referred to appropriate case management and services.

    • Adolescent Substance Use Disorder (SUD) screening, utilizing a norm referenced validated tool specific for substance use shall be performed at annual EPSDT visits beginning at 12 years of age. Positive screening results require appropriate and timely referral for case management and services.

• Immunizations, as appropriate, based upon the recommendations established by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), and as outlined in AMPM Policy 310-M - Immunizations, are covered for DCS CHP members. DCS CHP encourages all members to visit their PCP for immunization administration. Pharmacists, and Pharmacy interns under the supervision of a pharmacist, may administer the flu vaccines to children 3 years of age and older.

  DCS CHP members are expected to receive all recommended vaccines, including the flu vaccine and HPV, unless medically contraindicated or the parent has requested a religious exemption. The caregiver is allowed to consent for all medically necessary vaccines. Immunizations for the express purpose of foreign travel are not covered.

  Providers are required to document immunization refusal or decisions not to immunize in the member’s medical record.

  Providers are required to document immunizations administered into the Arizona State Immunization Information System (ASIIS), and be registered with the Arizona Department of Health Services (ADHS) Vaccines for Children (VFC) program to obtain and deliver VFC vaccine services for DCS CHP members.

• Laboratory tests, including evaluation for anemia, blood lead level to identify lead poisoning, Sexually Transmitted Infections (STIs), Human Immunodeficiency Virus (HIV), Sickle cell trait (if not previously tested) and other medically necessary and appropriate evaluations as indicated by the EPSDT exam and visit history are covered.

• Social-Emotional/Behavioral Health Screening:

  • Intimate Partner Violence (IPV) and Domestic Violence (DV) screening is recommended for all age groups in an appropriate manner to protect the parent if there is a disclosure as well as a teen if the teen discloses IPV or DV.

  • Notification of any aspect that threatens the safety of the children/youth in DCS CHP, who are all in DCS care, is prompt and is achieved by a call into the DCS Child Abuse hotline as needed.

• Oral health assessment, screening, treatment, education and referral at the EPSDT visit is performed by the PCP. The oral screening is intended to identify gross dental or oral lesions but is not a thorough clinical examination and does not involve making a clinical diagnosis resulting in a treatment plan. The oral health screening does not substitute for examination through direct referral to a dental provider. PCPs refer members for appropriate services based on needs identified through the screening process and for routine dental care based on the AHCCCS EPSDT Periodicity Schedule, AHCCCS Dental Periodicity Schedule, and AMPM Policy 431. Evidence of this referral is documented on Attachment E - AHCCCS EPSDT Clinical Sample Templates as specified in AMPM Policy 430, and in the member’s medical record. Oral health assessment and should include:

  • Evaluation of child/teen for oral health issues (tooth decay, indications of systemic illness etc.);

  • Application of fluoride varnish for members up to two years of age, may be applied four times a year (i.e. one every three months), with at least one tooth eruption during an EPSDT visit for children who have reached six months of age with at least one tooth erupted, with recurrent applications up to five years of age. Application of fluoride varnish is reimbursed according to the AHCCCS approved fee schedules. The PCP must be trained on the application of fluoride varnish, and have proof of certification, in order to be able to bill for this screening. Application of fluoride varnish by the PCP does not take the place of an oral health visit at the dental home;

  • Counsel on cleaning teeth, caries prevention and caries as a contagious illness, parental recognition of early caries or gum disease, the importance of dental sealants, fluoride supplementation, and anticipatory guidance related to oral hygiene, nutrition and caries, non-nutritive sucking, dental trauma in sports and prevention among other topics;

  • If the child does not have a dentist, the PCP may refer them to a Dental Home, or contact the health plan to assist the family.

• Vision Screenings and services are covered under the EPSDT benefit. The provider should be assessing vision at every EPSDT visit and as medically necessary, with age appropriate, standardized vision screening tools. Ocular photo vision screening with interpretation and report, bilateral is a covered test for children 3 through 6 years of age as part of the EPSDT visit. Billing for this service is limited to a lifetime coverage limit of one. Abnormalities on screening should be referred for further evaluation and treatment. Prescription lenses and frames are covered under EPSDT when medically necessary, as are the replacement or repair of eyeglasses, lenses and frames for members under the age of 21.

• Hearing assessments, screening and services are required at every EPSDT visit according to AHCCCS EPSDT Periodicity Schedule, Hearing /Speech Schedule. Medically necessary audiology services to evaluate hearing loss for all members are provided on an inpatient and outpatient basis. Hearing aids are covered only for members under the age of 21 receiving EPSDT services. Newborns must have their hearing screening in the newborn nursery prior to discharge and at every EPSDT visit for infants. Physicians should:

  • Review the results of the newborn hearing screening to follow up on any needed referrals. Infants who have not been screened, missed screening, or failed their hospital hearing screening, must be immediately referred for a rescreening in the first month of life and be referred to ENT for formal audiologic evaluations in the first 3 months of life.

  • Continue to assess for hearing loss at subsequent visits. A normal newborn screen does not mean the child has normal hearing;

  • Assess for any medical conditions related to hearing loss and make the appropriate referrals; and

  • Ensure that all infants with confirmed hearing loss are referred to and receive services before turning 6 months of age.

• Speech screenings should be performed to assess the language development of the member at each EPSDT visit.

• Tuberculosis (TB) Screening: Tuberculin (TB) skin and other TB testing, for age appropriate members, is given additional consideration as these children and youth maybe at higher risk because of their living environments. Risk factors include:

  • Living in a group home; or

  • Contact with individuals confirmed or suspected as having TB; or

  • Contact with individuals in a crowded living environment such as jail or prison during the last five years; or

  • Living with a family member who may be HIV infected; or

  • If the child has an HIV infection; or

  • If they have traveled or immigrated from or have significant contact with individuals who come from countries where TB may be endemic.

  Providers are expected to arrange for timely reading to TB skin tests and to conduct follow up evaluations, treatment and care coordination if indicated by the results of the test.

• Blood Lead Screenings: All children 6 months through 6 years old are recommended to have a lead screening questionnaire/assessment completed at each EPSDT visit. All children ages 12 months and 24 months of age must have a blood lead test. In addition, children between the ages of 24 months through six years of age who have not been previously tested, or who missed either the 12 month or 24-month test, must have a blood lead test. Additional testing for children through 6 years of age is based on the child’s risk as determined by either the residential zip code or presence of other known risk-factors, or as indicated by the provider assessment.

  If the provider conducts capillary sampling or fingerstick evaluation of lead levels, any result that is greater than the normal level as per the current Center for Disease Control (CDC) and Prevention recommended blood lead reference values is confirmed by a venous blood sample.

  Providers are expected to report blood lead levels to Arizona Department of Health Services (ADHS) as required under (A.A.C. R9-4-302).

  Providers are expected to follow up on and coordinate care with the Arizona Department of Health services, the contracted MCO and any specialists for repeat testing as indicated and to manage the care of a member with elevated blood lead levels.

• Anemia screening via a hemoglobin blood test is recommended for all infants at 12 months of age and at any other age if medically necessary.

• Diagnostic testing for Sickle Cell trait (if a child has not been tested previously) can also be done at the same time as the lead and anemia screening tests.

• DCS CHP members receive health education which includes age-appropriate anticipatory guidance at the EPSDT including, but not limited to:

  • Developmental milestones;

  • School performance;

  • Proper Nutrition and elevated BMI as indicative of obesity;

  • Physical activity;

  • Safety topics appropriate to each age group;

  • Oral health care;

  • Family planning/preconception counseling, and methods including Long Acting Reversible Contraception (LARC);

  • Pregnancy related nutrition guidance and inter pregnancy intervals for safe and healthy pregnancies;

  • Chronic disease management and self- management;

  • Emotional wellness;

  • Tobacco and substance use; and

  • Intimate Partner Violence/Domestic Violence.

Providers are expected to provide complete EPSDT services that encompass all aspects of the EPSDT visit. For teens this includes Well Woman/Man Preventive Care that can be provided by the PCP or by a qualified obstetrician (OB) provider in the case of a pregnant teen.

Providers are also required to educate families on the expectations of future EPSDT visits and coordinate follow up appointments and referrals for conditions identified at the visit.

All completed EPSDT forms submitted are reviewed for:

• Referrals made at the EPSDT visit are scheduled and/or completed;

• Care coordination needed;

• Completion of screening;

Referrals for treatment of conditions determined at the EPSDT visit are coordinated with the caregiver, the custodial agent (the DCS Specialist), primary care and specialty providers, and other agencies including but not limited to AzEIP.

Procedure

EPSDT Clinical Sample Templates

The contracted MCO maintains an EPSDT database that includes information provided on the EPSDT Clinical Sample Template. Providers are required to submit EPSDT Clinical Sample Templates, or the electronic equivalent, with their claim. The information is used to address AHCCCS requirements and reports, monitor EPSDT utilization, address areas that need improvement and to develop Performance Improvement Projects (PIPs).

Referrals

EPSDT Clinical Sample Templates are reviewed, referrals made by the PCP are tracked for verification of completion or if needed care coordination. Copies of the EPSDT Clinical Sample Templates received with referrals to DDD, CRS, ALTCS, Behavioral Health, Developmental, and AzEIP are forwarded to the appropriate department coordinator and member outreach is conducted.

Member and Provider Outreach for EPSDT

DCS CHP, through its contracted Managed Care Organization (MCO), conducts member and provider outreach in the form of general information, as well as member specific reminders for EPSDT visits, dental visits and immunizations.

DCS CHP and its contracted MCO informs all primary care providers (PCPs) about the requirements of the EPSDT program, including federal requirements, state regulations, and AHCCCS policy requirements and ensures all provider materials are accurate and aligned with AHCCCS policies. The health plan conducts provider outreach by fax, mail, and in-person office visits to inform providers of EPSDT requirements as well as review provider specific performance.

DCS CHP and its contracted MCO informs all health care providers initially and on an ongoing basis about EPSDT services, including federal requirements, state regulations, and AHCCCS policy requirements. DCS CHP reviews member and provider materials prior to dissemination to ensure accuracy and alignment with AHCCCS policy

Provider Compliance

DCS CHP and its contracted MCO measures, monitors, and implements provider activities to improve member participation rates for age appropriate screenings, according to the most current periodicity schedule. This includes, but is not limited to:

• Targeted blood lead screening/testing (if applicable)

• Developmental/behavioral assessments,

• Immunizations, and

• BMI/growth percentile.

DCS CHP and its contracted MCO reviews medical records for provider compliance with completing all the elements of the AHCCCS-approved EPSDT Clinical Sample Templates during each well-child visit, including reviewing records for key screenings, such as:

• Blood lead testing,

• Developmental screenings,

• BMI,

• Behavioral health,

• Substance use,

• STIs,

• Adolescent suicide screening, and

• Availability of family planning services and supplies (as appropriate for age at visit), as specified in AHCCCS policy.

EPSDT Clinical Sample Template forms are reviewed for completeness and for any potential grievances or quality issues. Any concerns regarding quality or completeness of EPSDT templates/exams are referred to the EPSDT Coordinator for intervention. Interventions may include provider outreach for education, possible Quality of Care (QOC) investigations, and potential claims recoupment. Providers are required to be certified to conduct the developmental screening tools and application of fluoride varnish in order to bill for those services. If providers are identified as not certified but are billing for those services, payments for those services may be recouped.

EPSDT Reporting

DCS CHP in conjunction with Mercy Care utilize EPSDT data for performance measure generation, tracking and trending, and in the generation of the EPSDT and Adult Quarterly Monitoring Report and performance measures. These reports and data are reviewed at quarterly Quality Management and Medical Management meetings as applicable. The data is discussed, reviewed for trends, appropriate goals, interventions and action plans for process improvement identified, and incorporated into quarterly reports, annual plans and program changes. The EPSDT and Adult Quarterly Monitoring Report is submitted on a quarterly basis to AHCCCS.