Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) or Medicaid for children is administered under the name Health Check in North Carolina and is jointly overseen by Clinical Policy and Programs and Managed Care. EPSDT is a federal requirement that mandates state agencies to provide services, products, or procedures requested by physicians and licensed clinicians for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified by a screening examination. Services provided under EPSDT include periodic screening, vision, dental, and hearing services. There is no requirement that the requested service, product, or procedure be included in the state Medicaid plan. However, the requested service, product, or procedure must be within the scope of the services listed in the Social Security Act (the Act) at 1905(a). For additional information about EPSDT, please refer to Section I. of this manual section and the website at http://www.ncdhhs.gov/dma/medicaid/healthcheck.htm.
Health Check and EPSDT services do not count toward a recipient’s annual professional services visit limit. Service limitations on scope, amount, duration, and/or frequency described in this manual and in clinical coverage policies may be exceeded or may not apply provided documentation supports that the requested service is medically necessary to correct or ameliorate a defect, physical and mental illness, or a condition identified by a licensed clinician. In accordance with EPSDT requirements, health care services shall be provided in a frequency and amount to reasonably achieve their purpose and shall be consistent with the recipient’s medical needs.
REVISED 08/01/11 – CHANGE NO. 14-11
There are no copayments.
Prior approval may be required for some covered state Medicaid plan services, products, or procedures before they can be provided. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval. Additionally, all services, products, or procedures that are not covered in the North Carolina State Plan MUST be approved before the service is rendered.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.