Health Check and Early Periodic Screening, Diagnostic and Treatment (EPSDT) Information for Providers about Medicaid Services for Children

Federal law requires that Medicaid-eligible children under the age of 21 receive any medically necessary health care service covered by the federal Medicaid law, even if the service is not normally included in the N.C. State Medicaid Plan.

This requirement is called Early Periodic Screening, Diagnostic and Treatment (EPSDT). All children covered by N.C. Medicaid are entitled to receive periodic screening, vision, dental, and hearing services.

Certain limits on services documented in Medicaid's clinical coverage policies may not be applicable to recipient under 21 years of age. The recipient's physician or licensed clincian can provide guidance about whether the service is medically necessary to correct or ameliorate the recipient's condition.

Many services require prior approval. The fact that a recipient is under the age of 21 does not eliminate the requirement for prior approval.

Services that are not covered by Medicaid may be provided to Medicaid recipients under the age of 21 if they are medically necessary. However, only those services that may be covered under federal Medicaid law can be considered for approval. If the recipient needs a service not covered by the N.C. Medicaid program, the provider should submit a Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years of Age on behalf of the recipient to:

Director
c/o Assistant Director for Clinical Policy and Programs
Division of Medical Assistance
2501 Mail Service Center
Raleigh, NC 27699-2501
Fax: 919-715-7659

A full explanation of the EPSDT policy and how to obtain approval for services can be found in:

• January 2006 Special Bulletin, Prior Approval Process and Request for Non-Covered Services
• December 2005 Special Bulletin, Medicaid for Children: Early Periodic Screening, Diagnostic and Treatment and Health Check

For additional information, refer also to:

• EPSDT Policy Instructions Update, August 2007
• Health Check and Health Choice: Basic Information for Providers from the N.C. Healthy Start Foundation

Health Check and EPSDT Consumer Information

Announcements

• EPSDT Policy Instructions Update, August 2007

Quick Links

• Clinical Coverage Policies
• Proposed Policies
• Basic Medicaid Billing Guide
• Health Check Billing Guide
• Health Check Provider Info

EPSDT Training Slides

• Basic Provider EPSDT Training
• Comprehensive Provider EPSDT Training