Payment is made to eligible providers
for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services on
behalf of eligible individuals under the age of 21.
(1) The EPSDT program is a
comprehensive child-health program, designed to ensure the availability of, and
access to, required health care resources and help parents and guardians of
Medicaid-eligible children and adolescents use these resources. An effective
EPSDT program assures that health problems are diagnosed and treated early
before they become more complex and their treatment more costly. The physician
plays a significant role in educating parents and guardians about all services available
through the EPSDT program. The receipt of an identified EPSDT screening makes
the member eligible for all necessary follow-up care that is within the scope
of the SoonerCare program. Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) covers services, supplies, or equipment that are determined to be
medically necessary for a child or adolescent, and which are included within
the categories of mandatory and optional services in Section 1905(a) of Title
XIX, regardless of whether such services, supplies, or equipment are listed as
covered in Oklahoma's State Plan.
(2) Federal regulations
also require that the State set standards and protocols for each component of
EPSDT services. The standards must provide for services at intervals which meet
reasonable standards of medical and dental practice. The standards must also
provide for EPSDT services at other intervals as medically necessary to
determine the existence of certain physical or behavioral health illnesses or
(3) SoonerCare providers
who perform EPSDT screenings must assure that the screenings they provide meet
the minimum standards established by the Oklahoma Health Care Authority in
order to be reimbursed at the level established for EPSDT services.
(4) An EPSDT screening is
considered a comprehensive examination. A provider billing SoonerCare for an
EPSDT screen may not bill any other Evaluation and Management Current Procedure
Terminology (CPT) code for that patient on that same day. It is expected that
the screening provider will perform necessary treatment as part of the
screening charge. However, there may be other additional diagnostic procedures
or treatments not normally considered part of a comprehensive examination,
including diagnostic tests and administration of immunizations, required at the
time of screening. Additional diagnostic procedures or treatments may be billed
independently from the screening. Some services as set out in this section may
require prior authorization.
(5) For an EPSDT screening
to be considered a completed reimbursable service, providers must perform, and
document, all required components of the screening examination. Documentation
of screening services performed must be retained for future review.
(6) All comprehensive
screenings provided to individuals under age 21 must be filed on HCFA-1500
using the appropriate preventive medicine procedure code or an appropriate
Evaluation and Management code from the Current Procedural Terminology Manual
(CPT) accompanied by the appropriate "V" diagnosis code.