Early and Periodic Screening, Diagnosis and Treatment Children’s Benefit: NC Medicaid Managed Care

What is the NC Medicaid EPSDT Benefit for Children?

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law (44 CFR Subpart B) that states that Medicaid must provide all medically necessary health care services to Medicaid-eligible children under age 21.

Even if a service is not covered under the NC Medicaid State Plan, it can be covered for beneficiaries under age 21 if the service is listed in 1905(a) of the federal Social Security Act and if all EPSDT criteria are met.

Preventative Services

EPSDT covers preventative services for beneficiaries under age 21, which include Health Check or wellness visits and comprehensive screenings. 

• All preventative services provided under EPSDT should include the EP modifier on the claims, submitted to the managed care health plan or NC Medicaid Direct. 
• These services do not require prior authorization. 
• Preventive services include wellness or Health Check visits and comprehensive screenings.

The required components of a Health Check visit are:

• A comprehensive health and developmental history that assesses both physical and mental health, as well as for substance use disorders
• A comprehensive, unclothed physical examination
• Appropriate immunizations in accordance with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices
• Laboratory testing (including blood lead screening appropriate for age and risk factors)
• Health education and anticipatory guidance for both the child and caregiver

Diagnosis and Treatment

EPSDT also covers Diagnosis and Treatment services. This includes treatment for conditions found during a comprehensive screening:

• If a service is not covered under the Medicaid State Plan, a request for coverage under EPSDT may be submitted for any Medicaid beneficiary under age 21. 
• EPSDT medical necessity reviews are conducted on a case-by-case basis by the managed care health plan that receives the request or by NCTracks or for pharmacy related requests, Prime Therapeutics for NC Medicaid Direct beneficiaries.
• Any request for non-covered services, or service requests that fall outside of the policy guidelines and limitations, do require prior authorization submitted to either the appropriate managed care health plan, or to NCTracks or Prime Therapeutics for pharmacy related requests, if the beneficiary is covered under NC Medicaid Direct.
• Requests for diagnosis and treatment services do not require an EP modifier but do require an approved prior authorization. 

All diagnosis and treatment services must meet EPSDT medical necessity criteria, including:

• Be medical in nature
• Be coverable under §1905(a) of the Social Security Act
• Not be experimental or investigational
• Be generally accepted as an appropriate method of medical practice or treatment
• Be safe
• Be effective

Requests for Covered Services

• Requests for covered services for an individual under age 21 are made to the appropriate health plan through their standard process or through NCTracks for beneficiaries in NC Medicaid Direct. 
• If it is within the clinical policy coverage guidelines, the request is reviewed the same as any other request. 
• If the request is for a covered service, but falls outside of the clinical coverage guidelines, it will be reviewed under EPSDT criteria. If the request meets the federal EPSDT criteria, it may then be approved. If it is not approved in full after being reviewed under EPSDT criteria, then a notice of Adverse Benefit Determination is sent to the beneficiary.
• The beneficiary has the right to appeal any Adverse Benefit Determination. Please review the Health Plans policies and procedures for information on how to submit an appeal for that designated Health Plan. This information can also be found in the Adverse Benefit Determination letter, which is sent by NC Medicaid Direct or the health plan, notifying the beneficiary of the denial.
• For NC Medicaid Direct beneficiaries, an appeal can be requested by mail, phone, fax or in-person. You have 60 days from the date the Adverse Benefit Determination was issued to file an appeal.
• EPSDT reviews are conducted on a case-by-case basis for all requests received for beneficiaries under age 21, ensuring they meet federal EPSDT criteria and that the requested service is medically necessary to “correct or ameliorate” a defect, physical or mental illness or a condition that is identified through a screening examination.

Limits Within Clinical Policy

The specific numerical limits (number of hours, number of visits, or other limitations on scope, amount or frequency) in NC Medicaid or the designated Health Plans clinical coverage policies, service definitions or billing codes do NOT apply to recipients under age 21 if more hours or visits of the requested service are medically necessary to correct or ameliorate a defect, physical or mental illness, or condition. 

Other restrictions in the clinical coverage policies, such as the location of the service, prohibitions on multiple services on the same day or at the same time (e.g., day treatment and residential treatment) must also be waived under EPSDT as long as the services are medically necessary to correct or ameliorate a defect, physical or mental illness, or condition. 

Prior Authorizations

• Requests for prior authorization of services must be fully documented to show medical necessity. 
• Requests should include current information from the beneficiary’s physician, other licensed clinicians, the requesting qualified provider and/or family members or legal representative. 
• If this information is not provided, the health plan or NCTracks or Prime Therapeutics for NC Medicaid Direct will have to obtain the needed information, and this will delay the prior approval decision.
• The form to submit a non-covered service request for NC Medicaid Direct beneficiaries under age 21 is located here: Prior Approval.
• The managed care health plans may have separate forms and processes for submitting requests for non-covered services, and you can find those in their provider manuals.

Claim Reimbursement

Upon identification of an EPSDT claim per federal guidelines and requirements, all EPSDT claims are paid by NC Medicaid Direct and the health plans as the primary payers. Health plans are responsible for recovery from any liable third-party payer unless it has been determined as not cost-effective. EPSDT claims are exempt from the standard coordination of benefits regulations in which NC Medicaid is the payer of last resort.

Depending on how the provider bills, the health plan may need to pay and chase claims that would ordinarily be cost-avoided. For example, if a provider submits a bundled claim, and the bundled claim includes any cost-avoided services, suppose the cost-avoided services cannot be identified and adjudicated separately. In this case, the health plan must pay and chase the entire bundled claim to ensure compliance with federal requirements.

EPSDT Trainings

NC Medicaid is currently providing trainings to all NC Medicaid Managed Care health plans and reviewing their EPSDT processes and procedures to ensure they align with federal guidelines. NC Medicaid has also completed several trainings for providers on the EPSDT benefit for Medicaid beneficiaries under age 21. These trainings will continue to educate providers and beneficiaries about the services available to them and the guidelines around EPSDT. Please visit the NC Medicaid Wellness Visits, and Diagnostic and Treatment Services webpage for updated trainings.

For more information, please visit the Early and Periodic Screening, Diagnostic and Treatment Form.