469 NAC 5-001.03
The following terms are defined in relation to HEALTH CHECK and treatment services under the EPSDT program.
Early: As soon as an individual's or a family's eligibility for assistance has been established; or, in the case of a family already receiving assistance, as early as possible in the individual's life. This includes informing Medicaid women so that prevention begins prenatally.
Periodic: Intervals established for examination or screening to ensure continued health and to detect conditions requiring treatment. Dental screening examinations are recommended for children three and older according to the American Dental Association. If a dental problem is suspected before age three, a dental screening should occur at that time. Medical, visual, and hearing exams are to begin with a neonatal exam and follow, at a minimum, the periodicity schedule based on the American Academy of Pediatrics schedule for health supervision visits (see 471 NAC 33-002.03). The physician may establish an alternate periodicity schedule based on medical necessity. The initial examination of a newborn is considered an initial HEALTH CHECK (EPSDT) examination and the child is considered participating in the program. Well-baby and well-child examinations are to be reported as HEALTH CHECK examinations through the HEALTH CHECK EPSDT program.
Screening Services: Periodic child health assessments which are regularly scheduled to examine and evaluate the general physical and mental health, growth, development and nutritional status of eligible children. The screenings are performed to identify those who may require diagnosis, further examination, and/or treatment. Prior authorization approval of health, dental, vision, and hearing screening examinations for EPSDT participants is prohibited. The following screening services are included in the EPSDT benefit:
1. Health Screening Services:
a. Comprehensive health and developmental history (including assessment of both physical and mental health development);
b. Comprehensive unclothed physical examination;
c. Appropriate immunizations for age and for health history;
d. Appropriate laboratory procedures for age and populations groups; and
e. Health education (including anticipatory guidance);
2. Dental Screening Services: For children age three and older, dental screening services are furnished by direct referral to a dentist. Children age two and younger are screened by the screening physician as part of the health screening exam. If a dental problem is suspected before age three, a referral to a dentist for a dental screening should occur. Medically necessary and reasonable diagnosis and treatment including, at a minimum, relief of pain and infections, restoration of teeth, and maintenance of health are covered;
3. Vision Screening Services: An age-appropriate visual assessment. Medically necessary and reasonable diagnosis and treatment for defects in vision are covered; and
4. Hearing Screening Services: An age-appropriate hearing assessment. Medically necessary and reasonable diagnosis and treatment for defects in hearing are covered.
Diagnosis: The determination of the nature or cause of a physical or mental disease or abnormality. A diagnosis enables a physician to make a plan for treatment specific to the EPSDT participant's problems. Under certain circumstances, diagnosis may be provided at the same time as screening. In other circumstances, diagnosis may be provided during a second appointment. The diagnosis may or may not require further follow-up. It may result in referral for treatment.
Treatment Services: HEALTH CHECK (EPSDT) follow-up services necessary to diagnose or to treat a condition identified during a HEALTH CHECK (EPSDT) health, visual, hearing, or dental screening examination are covered under the following conditions:
1. The service is required to treat the condition (i.e., to correct or ameliorate defects and physical or mental illnesses or conditions) identified during a periodic or interperiodic HEALTH CHECK (EPSDT) screening examination and documented on the screening claim form (Form MC-5, Form HCFA-1500, dental claim form);
2. The provider of services is a Medicaid-enrolled provider;
3. The service is consistent with applicable federal and state laws that govern the provision of health care;
4. The service must be medically necessary, safe and effective, not considered experimental/investigational (see 471 NAC 10-004.05), and must be generally employed by the medical profession;
5. Supplies, items, or equipment that is determined to be not medical in nature will not be covered;
6. Where alternative and medically appropriate modes of treatment exist and are available the NMAP may choose among the alternatives which services are available based on cost-effectiveness;
7. Services currently covered under the Nebraska Medical Assistance Program will be governed by the guidelines of NMAP;
8. Services not covered under the Nebraska Medical Assistance Program but defined in Section 1905(a) of the Social Security Act must meet the conditions of items 1 through 4 (above). Criteria and requirements for certain services are outlined in 471 NAC 33-000. Unless otherwise outlined, all services not covered under NMAP must be prior authorized by the Medical Services Division, Department of Social Services. Requests for prior authorization must be sent to: Nebraska Department of Social Services, Medical Services Division, EPSDT Coordinator. The screening practitioner shall submit the request which must include:
a. A copy of the screening exam form or the name of the screening practitioner and the date of the screening exam which identified the condition; and
b. A plan of care which includes:
(1) History of the condition;
(2) Physical findings and other signs and symptoms, including appropriate laboratory data;
(3) Recommended service/procedure, including (if unknown) the potential provider of service (e.g., equipment, supplies) or where the services will be obtained;
(4) Estimated cost, if available; and
(5) Expected outcome(s).
The plan of care may be submitted on Form EPSDT-5, "Plan of Care," or as a statement by the screening practitioner. The Medical Director or designee shall make a decision on each request in an expeditious manner. Appropriate health care professionals may be consulted during the decision-making process. A copy of the decision will be sent to the screening practitioner and the client's worker in the local Social Services office. For wards of the Department, a copy of the decision is sent to the client's case manager in the local office. If the initial request is denied, additional information may be sent for reconsideration.
{5/8/05}