Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program/Child-health Services

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to eligible providers for Early and
					 Periodic Screening, Diagnostic and Treatment (EPSDT) services on behalf of
					 eligible individuals under the age of twenty-one (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,
				  Diagnostic 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 Medicaid 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
				  conditions.
(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)
				  If a member is receiving an EPSDT screening and an additional focused complaint
				  arises that requires evaluation and management to address the complaint, the
				  provider may deliver all medically necessary care and submit a claim for both
				  the EPSDT screening and the appropriate level of focused service if the
				  following requirements are met:
(i) The
				  medical issue is significant enough to require additional work to address the
				  issue;
(ii) The visit is documented
				  on a separate note;
(iii)
				  Appropriate documentation that clearly lists the condition being managed at the
				  time of the encounter and supports the billing of both services; and
(iv) Modifier 25 is added to the appropriate
				  code that indicates that a separate evaluation and management service was
				  provided by the same physician on the same day as the EPSDT screening. All
				  claims submitted with Modifier 25 will be reviewed prior to payment, per
				  Oklahoma Administrative Code (OAC)
				  317:30-3-33. The following items
				  will be reviewed prior to any payment:
(I)
				  Medical necessity;
(II) Appropriate
				  utilization of Modifier 25; and
(III) All documentation to support both the
				  EPSDT screening and the additional evaluation and management for a focused
				  complaint must be submitted for review.
(v) All claims are subject to a post payment
				  review by the OHCA's Program Integrity Unit.