Beech v. Melancon Petition for Writ of Certiorari to the United States Court of Appeals for the Sixth Circuit
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January 1, 1972
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Case Files, Matthews v. Kizer Hardbacks. Louisiana Medical Assistance Program EPSDT Services Provider Manual, 1991. f50414b6-5c40-f011-b4cb-7c1e5267c7b6. LDF Archives, Thurgood Marshall Institute. https://ldfrecollection.org/archives/archives-search/archives-item/bf1e175f-63d4-450c-9f4f-907b99b73d9f/louisiana-medical-assistance-program-epsdt-services-provider-manual. Accessed June 17, 2025.
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Louisiana Medical Assistance Program
EPSKT Services Provider Manual
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2. EARLY AMD PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES
NOTE: All of the EPSDT policies and procedures delineated in Section
2 of this manual are effective July 1, 1990 unless otherwise stated.
2.1. OVERVIEW
EPSDT is the nation's most comprehensive health program of prevention and
treatment for low income children. 2
2.1.1 Legal Basis
EPSDT services were established by Title XIX of the Social Security Act in
1967. Sections 1902 (a) (43), 1905(1)(4)(B) and 1905(r) of the Act, as
amended, set forth the basic requirements for the services. Louisiana adopted
EPSDT services in 1972. Significant changes were made in the services as a
result of passage of the omnibus Budget Reconciliation Act of 1989 (OBRA-89)
by Congress.
2.1.2 Purpose and Scope
The purposes of EPSOT services are:
a. To actively seek out all eligible families and educate them on the
benefits of preventive and continuous health care;
b. To help eligibles effectively use health resources and encourage them to
participate in screenings at regular intervals;
c. To provide for the detection of any physical and mental problems in
children and youth as early as possible through comprehensive medical
screenings in accordance with program standards;
d. To provide for appropriate and timely diagnostic and/or other services to
correct or ameliorate any acute or chronic conditions found before the
health problems become more complex and their treatment more costly;
EPSOT screening, diagnosis and treatment services are available statewide to
Medicaid eligible children and youth under age 21. The amount, duration, and
scope of EPSOT services are not required to be provided to other Medicaid
recipients. Some EPSDT services may be limited based on medical necessity as
determined by the Bureau." Aoi y adi REWOL Le
2.1.3 ‘Definitions
The following terms are defined to assist providers in understanding the
conceptual framework and basic requirements of EPSDT services.’ :
a. Early: A Medicaid eligible child should begin to receive high quality
preventive health care as early as possible in his or her life.
2-1
Revised October 9, 1990
b.
d.
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
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Periodic: - Occurring “at regular intervals according to an established
schedule which meets reasonable standards of medical, vision, “hearing
“and dental - practice .established after consultation with recognized
professional organizations. '@ 5 nr Ed at 2 wv 3
screening: An examination using procedures to sort out apparently well
Children from those who have a disease, condition or abnormality and to
identify those who may need diagnosis, evaluation and/or .treatment of
their physical or mental problems. Four distinct types of screenings are
required: medical, vision, hearing, and dental. :
~The four screening types are listed below: rei
(1) Medical Screening - This consists of:
" (a) Comprehensive ‘health :and . developmental history, including
=... assessment of physical and mental development and nutritional
status;
(b) Comprehensive unclothed physical examination/assessment;
(c) Immunizations or determination of immunization status
appropriate for age and health history;
(d) Appropriate laboratory procedures according to age, risk,
health history and population groups;
(e) Health education, including anticipatory guidance aad
interpretive conference; -
(f) Care coordination.
(2) Vision Screening - This consists of history and observation for
children under age three (if testable) or age four and objective
visual acuity and color perception tests after age three (if
testable); otherwise, age four.
(3) Hearing Screening - This consists of history and observation for
children under age three (if testable) or age four and objective
~ audiometry testing after age three (if testable); otherwise, age
four. : i A3Y Sie’ E SR
(4) Dental Screening - This consists of oral inspection up to age three
and direct referral to a dentist for examination after age three or
“younger, if medically indicated. et
A partial screening consists of one or more components of a screening.
A screening which is provided more frequently or at a different interval
than the established periodicity schedule is called an interperiodic
screening,” © Tees LT a Heit ip :
Diagnosis (Evaluation): The determination of the nature or cause of
physical or mental disease, condition or abnormality when a medical,
vision, hearing, dental, or other screening examination indicates the
need for further evaluation of the child's health status.
2-2
Revised October 9, 1990
Ed
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
e. Treatment: One or more of physician's or dentist's services,
optometrist's services, podiatrist's services, hospital services
(inpatient and outpatient), clinic services, laboratory and X-ray
services, prescribed drugs, eyeglasses, hearing aids, prostheses,
physical therapy, occupational therapy, speech therapy, psychological
‘service, rehabilitation services, and any other type of health care or
other services to correct or ameliorate defects and physical and mental
illnesses or conditions found in the medical, vision, hearing and dental
screenings.
= - 3 I
a
2.1.4... EPSOT Organization and Administration
T mea
The Bureau of Health Services Financing (BHSF) is responsible for the overall
administration of EPSDT services consisting of the following mutually
supportive operational components: fo Fi : -
a. Outreach
b. Informing
Cs Referring
d. Preventive health services
(1) Medical screenings
(2) Vision screenings
(3) Hearing screenings
(4) Dental screenings
(5) Other health services
e. Diagnosis
f. Treatment ; ¥
g. Care coordination
h. Monitoring
The Bureau establishes the services standards and requirements which the
providers must meet. Certain administrative components are delegated to other
agencies and providers including informing, outreach and care coordination.
5.1.5 EPSDT Provider Enrollment
One of the goals of EPSOT services is to increase the number and types of
participating providers including more parish school systems, private
physicians in individual and group practices, community health centers, rural
health centers, Head Start agencies and other public and private outpatient
facilities providing health care to children. By developing a broad base of
qualified preventive and primary care providers in both the private and public
sectors, EPSOT services can facilitate access to preventive health care and
encourage families to develop a permanent provider relationship or "medical
home." This can assure more comprehensive care for children and can result in
the reduction of overall health costs over time.
Participation as an EPSDT provider is entirely voluntary. EPSDT Program
providers are not limited to those who are qualified to provide the full range
of medical, vision and hearing screening services. Although a qualified
provider may be enrolled to furnish one or more types of screening services,
the Bureau encourages qualified providers to provide the full range of
medical, vision, and hearing screening services to avoid fragmentation and
duplication of services.
2-3
Dauvicad October 9. 1880
Louisiana Medical Assistance Program
8
EPSDT Services Provider Manual Ha
P
i
EPSOT providers must meet all general enrollment conditions. described in
Section 1.4.2. They are also required to sign a supplement to the general
provider enrollment agreement (Form PE-50) which delineates specific EPSOT
provider requirements and responsibilities.
All providers who wish to participate in EPSDT must enroll for the specific
‘screening service or combination of screening services or health services they
wish to provide. Enrolling providers must meet all qualifications applicable
to the specific services they wish to provide. Providers of health services
to children with special needs must also sign a supplement to the Form PE-50
which delineates their specific provider requirements. Health service
providers are encouraged to enroll "as EPSDT medical, vision -and hearing
screening providers. on Taal de
The Bureau reviews potential medical screening provider applicants. This
process includes an on-site evaluation completéd by Bureau "staff and/or
individuals under contract to the Bureau. The site visit is made to assure
compliance with screening standards in the following areas: pd
Physical facility (sanitation, privacy, etc.)
Equipment maintenance and supplies
Screening procedures
Periodicity scheduling process
Referral and follow-up process
Record setup, documentation and retention of records
Billing/reporting procedures
Confidentiality, informed consent, release of information, civil
rights
9. Staffing qualifications and licensure
10. Outreach procedures
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Temporary approval is recommended for medical screening providers if
compliance with requirements for screening services appears feasible. A
follow-up site visit by Bureau staff and/or individuals under contract is.
.completed within six months after the medical screenings begin. Full approval
is recommended if all standards are met. This policy is effective July 1,
1990 for new medical screening providers.
A potential screening provider's application for enrollment may be denied or
pended, if the Bureau has notified the provider of any of the following
potential adverse actions: Sagi bia Pate a |
1. The provider has been criminally indicted or convicted of a criminal
37 toff@ns@s Tsim tuoiyo nm dna 1a 5 Plt ety ily cele
2. "A criminal investigation .is -in process with the Office of the
Attorney General; Bt = > gs
3. The provider has been suspended or terminated from the Medicaid
Program; ; LR : :
"4. The Bureau is seeking to withhold and/or recover monies ineligibly
: received by the provider. mR
Be. The provider's license is suspended or revoked.
2-4
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
2.1.5.1 Equipment Maintenance
All equipment must be checked on a regular basis to assure proper functioning.
All mal functioning equipment must be repaired or replaced as soon as possible.
Equipment must be calibrated and cleaned annually by an authorized repair
service source who can calibrate, clean, and maintain equipment according to
the manufacturer's instructions or specified standards. Proof of inspection
and calibration of each piece of equipment must be available upon request at
the screening site. Equipment maintenance will be checked as a part of
regular provider monitoring efforts. “All equipment must be listed on a MMIS
Form 24 and provided to tne Bureau upon enrollment. ‘An updated OFS Form 24
must be submitted as equipment is disposed of or purchased and submitted to
the Provider Enrollment Unit of the Bureau of Health Services Financing, Post
office Box 91030, “Baton ‘Rouge, Louisiana’ 70821-9030. This form may be
obtained from the Bureau at the address above or from the Unisys Provider
Relations Unit at P.O. Box 4169, Baton Rouge, LA 70821. To request by phone,
call Unisys at (504) 924-5040 in Baton Rouge; (504) 528-9846 in New Orleans;
or 1-800-737-8647 elsewhere in Louisiana. Out-of-state providers may contact
Unisys at (504) 924-5040. oe
2.1.5.2 Provider Identification Number
Each EPSDT provider will use a unique seven-digit provider number for billing.
School boards may have a separate provider number for screening services and.
services to children with special health needs (formerly referred to as school
health services).
The Provider Enrollment Unit of the Bureau may be contacted at the address and
phone number shown in Section 1.4.2 for more information on EPSDT provider
enrollment.
2.2 INFORMING AND OFFERING EPSDT SERVICES
2.21 Eligibles to be Informed and Offered Services
All Medicaid eligible recipients under 21 and their families must be promptly
and effectively informed about EPSDT services. Medicaid eligible families
must be informed and of fered EPSDT services within 60 days of certification by
the Office of Family support (OFS). This includes the following groups of
eligibles:
Tae ;
a. Newly eligible families determined eligible for the first time.
b. Families determined eligible after a period of ineligibility if they have
not used EPSOT services for at least one year. If no one who is eligible
in a family has utilized EPSDT services during a year, the family must be
re-informed annually.
Bi :
c. Medicaid eligible pregnant women. A Medicaid eligible woman's positive
response to an offer of EPSDT services during her pregnancy, which is
medically confirmed, constitutes a request for EPSDT services for the
child at birth.
:
Revised Oci.ver 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
d. Parents of deemed eligible newborns to be added to Medicaid assistance
units.
e. “parents of newborns who are not deemed eligible at birth must be informed
at the time the infant's eligibility is determined. i
Ff. Title IV-E foster care children in homes and institutions.
2.2. LF Responsibilities for Informing and Offering Services
The parish OFS staff and out-station eligibility staff in the Charity Hospital
Medical . Assistance Program (MAP) units, parish "health units -and other
facilities are responsible for explaining EPSOT and offering EPSOT services to
newly certified Medicaid eligibles, and -other ‘groups of eligibles except
foster children. -Qualified providers who determine presumptive Medicaid
eligibility in the CHAMP Program (see Section 1.5.3) are also responsible for
informing pregnant and postpartal women found to be presumptively eligible for
Medicaid, of the availability of EPSDT services for themselves, if they are
under 21 years old, and for their child at birth. . Hise
Providers of the Special Supplemental Food Program for Women, Infants and
Children (WIC) are required to inform WIC eligible pregnant or postpartal
women and parents of WIC eligible children under age five of the availability
of EPSDT services. ; .
The Office of Community Services (OCS) must inform foster parents, adoptive
parents receiving a subsidy, and administrators of institutions and group
homes about EPSDT services available for Title IV-E foster children on an
annual basis. Informing and offering EPSDT services must be done on a more
frequent basis if there is a change in placement.
Head Start agencies must explain EPSDT services to the parent(s) or
guardian(s) of Medicaid eligible children enrolled in Head Start Programs and
of fer referrals for EPSDT services. - - - - = - - 2.
2.2.1.2 Content and Method of Informing and Offering Services
Clear, non-technical language, using a combination of face-to-face interview
and written methods, must be used to describe EPSDT services, the benefits of
preventive health care, where the services are available, how to obtain them,
and that necessary transportation and scheduling assistance is available from
the parish OFS office. Medicaid eligible families must also be informed that
EPSOT services are provided without cost to them. They must also be given
freedom of choice in selecting screening and other health services providers
in the offer of EPSOT services at the eligibility interview. * The Bureau is
responsible for notifying the parish OFS of participating medical, vision,
hearing and dental providers. : if id
The required written method of informing and offering EPSODT services is the
revised OFS Form EPSOT 8 (Figure 2-2). OFS must complete and mail Form EPSDT
8 immediately at the time of certification advising the parent(s) or
guardian(s) of the address and telephone number of the available provider
Reviced October 9. 1990
~
-
Louisiana Medical Assistance Program - =
EPSDT Services Provider Manual :
selected by the family and how to contact the provider for a screening
appointment. OFS must also offer assistance in arranging transportation, if
needed by the recipient.
¥
A parental consent form must be signed during the eligibility interview on any
child referred to a participating school system for screening services. Upon
certification, the signed consent form must be immediately routed to the
appropriate EPSDT School Nurse Program.
:
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2.2.2. OuLreach .i5oioed Le TinTIiU anise Rt. he uni
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Outreach activities are critical to successful health screening services. The
outreach process assures that eligible families are contacted, informed, and
assisted in securing health screening services. This section addresses
outreach policies and activities for health screening providers.
Federal law requires that each state achieve an 80 percent participation of
Medicaid eligible children by 1995. Incremental annual participation goals
are mandated for each state using the 1989 screening rate as a baseline. In
1989, Louisiana reported a 33 percent screening rate. . The State must screen
over eight percent more children annually to reach its .goal by 1995.
Aggressive provider and recipient outreach are key elements of the Bureau's
strategy to accomplish this goal.
EPSDT screening providers must explain and offer EPSDT screening services to
Medicaid eligible families they serve. In addition, they are required to
furnish EPSDT screening ‘services to these families or refer the child to a
medical screening provider of the parent(s)' or guardian(s)' choice. EPSDT
screening services are targeted to the following groups:
Pregnant women and pregnant adolescents;
Adolescents receiving family planning services;
Families receiving any Title V funded services, including services of the
Handicapped Children's Services Program
Children receiving special ‘education services;
Parents of newborns -
parents of high risk infants and toddlers;
Families receiving WIC services; ~~
Families receiving Head Start services
2.3 SCREENING SERVICES STC SE
Medicaid - eligible children and youth from birth to age 21 are eligible for
© EPSDT screening services provided according to the periodicity schedules for
medical, vision, hearing and dental screening services.” ~‘'Since ” EPSOT
screenings are voluntary services, some children may decline a screening at
the appropriate time. . -This does not preclude the child from receiving
later date or receiving medically necessary diagnosis,
te from the screening.
esent at the screening, the child
t(s) or guardian(s) to participate
in screening services. The parent(s) or guardian(s) do not have to be present
at the screening.
Raviced October 9, 1990
Louisiana Medical Assistance Program
EPSOT Services Provider Manual
Form EPSOT 8
Revised 7/1/90
Prior Issue Obsolete
Date
ID No.
Dear *
You may recall that when you applied for Medicaid and/or Public Assistance,
you were informed of varjous services available. Medical, vision, hearing and
dental check-ups are offered at no cost to you for anyone up to the age of 21
who receives Medicaid. ~ These ‘check-ups are provided through Early and
Periodic Screening,’ Diagnosis and Treatment (EPSOT). ~:uivi 12-28 A
The free check-ups can help find health problems and treat .them before they
get worse. Regular check-ups are important even if you or your child is well
because they help to prevent illness." EPSDT services available include:
* Physical exams =~ ' °° -Eyeglasses
~ -Immunizations (baby shots) - . -=Hearing aids
-Vision check-ups . -Medical equipment
-Hearing check-ups -Nutrition/health education
-Dental check-ups -Other needed medical, dental and
.-Medicines health related services
You were given the names of providers available to provide EPSDT check-ups in
this parish when you applied. Please contact the provider you have chosen for
yourself (if you are under 21) or your child, as soon as possible and ask for
an EPSDT screening appointment. The provider's address and telephone number
is given below.
Recipient's Name(s)
Provider's Address
Provider's Telephone
Number(s)
. If .you need transportation to any EPSDT check-ups, please contact this Office
of Famiy Support at least two days before your appointment. : If you have any
questions, please contact me at _ i TE FI >
Sincerely,
Family Support Examiner
"Figure 2-2. OFS Form EPSOT 8
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
2.3.1 Periodicity
EpSDT eligible children and youth requesting screening services “must be
provided regularly scheduled examinations and assessments of their general
physical and mental health, growth, development and nutritional status,
vision, hearing and dental health status required at the intervals indicated
in Section 2.3.2.1. Scheduling initial and periodic screenings according to
the medical, vision, hearing and dental periodicity schedules and monitoring
provision of these screenings is the responsibility of screening providers who
provide full medical screening services. . These providers are reimbursed for
the additional responsibility of scheduling and coordinating the care of these
children and the costs of administering these required EPSDT activities.
Screening providers may also opt to provide only medical, vision, hearing or
dental screening services. To prevent duplication of services, the EPSDT
screening provider -should not perform a screening if written verification
exists or if notified by another provider that the child has received the most
recent age appropriate medical, vision, hearing or dental screening unless
the additional interperiodic screening is requested by the parent or is
medically necessary. Every effort should be made to assure that medical,
vision and hearing screenings, including giving immunizations due, are
accomplished in one visit and that fragmentation or duplication of screening
services is prevented.
Figure 2-3 is the medical, vision, hearing, and dental screening schedule
which EPSDT screening providers must follow. The schedule has been developed
in consultation with recognized medical, dental and other professional
organizations involved in child health care in Louisiana. The following
sections describe those policies relevant to the provision ical, vision,
hearing, and dental screenings. Screening providers( must perform all
screening services at the appropriate age intervals in Yccordance with the
description under each distinct type of screening described below.
2.3.1.1 Interperiodic Screenings |
EPSOT eligible children may receive medical, vision, hearing and dental
services which are medically necessary to determine the existence of suspected
physical or mental illness or conditions, regardless of whether such services
coincide with the periodicity schedule for these services. Screenings which
are performed more frequently or at different intervals than the established
periodicity schedule are called interperiodic screenings. An interperiodic
screening may be performed based on a request by the parent(s) or guardian(s)
(e.g., to get the child on the same screening schedule as other children in
the home) or based on the provider's professional judgment relative to medical
necessity. | ear TT
‘The determination of whether an interperiodic screening is medically necessary
may also be made by a health, developmental or educational professional who
canes into contact with the child outside of the formal health care system
(e.g., state early intervention or special education programs, Head Start and
day care programs, the Special Supplemental Food Program for Women, Infants
‘and Children (WIC) and other nutritional assistance programs). The provider
must document in the child's health record the source of the request and
medical necessity. Le : Ah :
2-9
Daviced Nctober 9. 1990
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REQUIRED MEDICAL, VISION, HEARING AND DENTAL SCREENING COMPONENTS BY
\
AGE OF RECIPIENT (EFFECTIVE OCTOBER 1, 1990)
Key X = Required at-the visit for this age = - S = Subjective by history and observation
comes = One test must be administered during this time frame
1 if a child comes under care for the first time at any point of the schedule, or if any components are not accomplished
rge (usually within 24 hours of birth except for metabolic
schedule should be brought up to date at the earliest possible time.
2 Ihe newborn screening at birth must occur within 24 hours of birth prior to hospital discha
screening.)
; The physical examination/assessment must include an oral/dental inspection. .
Urine screening (dipstick) is to be done once between birth and two years, once between two an
5 years
Health education sust include antici atory guidance and interpretive conference. . Youth, age
education which addresses psychological, emotional, substance usage and reproductive health issues 2
0 = Objective by standard testing method
A child must be referred for an annual complete dental screening beginning at age three to age 21.
at the recommended age, the
AGE Birth Aah Li LAT EREREN - lv RRR ALBREL $0
:
| rw. r Yr. Yr Ir Yr Yr
MEDICAL SCREENING malar ela wd lai] x Ly Lx lx LX tind Patly yg Tagslay
Inftial/interval History | x fox | x } x } x } x { Xx LX ria by bowl n Ll lon adopt Lox
Measurements
dat WME Sh
Height and Weight x lx della] x jx jx xix x i aly by owl po aly
Head Circumference’ X X x | x | «x X X Xi]. X fx y
Blood Pressure
Ly ply Lop loxley Bago] yo boy bX x
Developmental Assessment | s | s 1 o | s | 5 {----}-0 LS s lo lo lo leido ls Vs jg tgs 15 1S
Inspections y
:
a
Physical Exam/hssessment®] x1 x] x lx 1x 1x 1X 1X tle} yl telly e Fels PX 12 LX
Procedures
| * :
Immunization
X X X X X eemofo-Koo]om--- X--|----
Metabolic Screening -e-]--X-
Sickle Cell Screening | -:-]--X-
Anemia Screening A ---|--X- tf gdp yl yl vx: yx Lx 7x 2 NX
Urine Screening? |----- he a I Tm RTD RE EE EE Ta om or es OD 0 EE TAR Bd ole Baia Wi
Lead Screening
X X X X X .
Nutritional Assessment x ft Sy yl ably on tx {oy Xf XX YY lx Yxl.xl:y 3 x 1X
Health Education’ t | x lal al xl xl al slag xx xed cX td tx lx won lo
VISION SCREENING _ sj wl gto dye] ols sl $1.8 Jopclb o lologlo-l..-.10180-1---10
HEARING SCREENING s sel els! ols]sts)ls dof-0-r0LblS 0--| ---] o | 0--]---] 0
DENTAL SCREENINGS
ELE EERER bd gow dy Ty
d five years, five and twelve years, and twelve and 21
s 12 through 20, must receive more intensive health
t each screening visit.
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual
2.3.2 Medical Screening
2.3.2.1 Medical Screening Periodicity Schedule
Children under two years old must be screened within 60 days from the date of
the request for an initial screening. Medical screening providers must screen
children ages two and over within 120 days from the date of the request. This
is the date the parental consent form is received by the EPSDT School Nurse
Program. For other providers, the date of the request is the date the
provider contacts or is contacted by the recipient for screening services.
Effective October 1, 1990, screenings must, at a minimum, be performed in
accordance with the schedule listed below. This schedule of 21 visits between
birth and 21 years follows the recommended schedule of visits of the American
Academy of Pediatrics Guidelines for Health Supervision II.
a. - Birth (prior to hospital discharge)
b. By one month
C, Two months
d. Four months
e. Six months
f. Nine months
g. 12 months
h. 15 months
i. 18 months
h Two years
k. Three years
1. Four years
m. Five years
n. Every two years from age six to 20.
Between July 1, 1990 and October 1, 1990, the required medical screening
periodicity schedule includes screening at the age intervals listed above with
the exception of at birth (prior to hospital discharge) four, nine, 15 and 18
months. However, medical screening providers may also opt to implement the
full 21-visit schedule immediately rather than waiting until October.
Screening must be provided in the month or calendar year (beginning at age
two) they are due. For example, the screening due when the child is six
months old must. be provided between the sixth and seventh month. The
screening due when the child is two years old must be provided between the
child's second and third birthdays. Screenings that are due every year, e.g,
in the second through the sixth year of life, must be provided at least six
months apart. TE CONE : ey
2-11
Daviced October 9. 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual . .
2.3.2.2 Medical Screening Requirements
Medical screenings include all of the following services:
a. A comprehensive health and developmental history, including assessment of
. both physical and mental health development and nutritional status; -
b. A comprehensive unclothed physical examination/assessment;
ee Determination Of immunization status and provision of appropriate
immunizations according to age and health history; ~~ ~~~ 5g an
d.- Appropriate laboratory tasts according. to ‘age, risk, health history and
- - population group; AME NA ts RU Ete ;
: £3 7 3 7 ap “Thi Fi FNS EL IE,
e. Health education ‘(including interpretive conference);
Xs Care coordination;
2.3.2.3 Description of Medical Screening Requirements
The required medical screening services are described in detail below. Each
service of the complete medical screening is performed at the intervals
specified in Figure 2-3. These services must be provided at the same visit,
unless the child is uncooperative or the procedure is medically
contraindicated on the date of the medical screening or the screening provider
does not routinely administer immunizations to children. A written consent
form from a parent ‘or guardian must be presented if the child is seen alone.
a. Comprehensive Health and Development History
This information must be obtained at each medical screening visit from
the parent(s) or guardian(s) who is familiar with the child's history and
must include an assessment of . both physical and mental health
development. The initial health history (modified for age) must include
the . family's health history, the child's health history, physician's
name, dentist's name, pregnancy and birth history, developmental
milestones, immunization history, food history, feeding or nutrition
problems, behavioral indicators of stress or emotional problems, sexual
development and a review of body systems. - Subsequent histories may be
-specific for the child's age and past medical history. A physician,
physician assistant or registered nurse must review and interpret - the
health history for high-risk factors or indications of suspected disease
or abnormalities with the parent(s) or guardian(s) or youth (if
appropriate) in the interpretive conference. ena Le
If the child's parent(s), guardian(s) or other responsible adult is not
present to provide this information, the parent(s) or guardian(s) must be
contacted by telephone by the provider or a questionnaire must be sent to
the child's home to gather the information. A responsible adolescent or
young adult may provide this information in certain instances. If these
options are not feasible or are not successful, the provider must visit
the child's parent(s), guardian(s) responsible adult to obtain the
necessary information.
2-12
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
Developmental Screening
A comprehensive developmental history to determine if motor, speech,
language, and psychological problems exist or to detect the presence of
any developmental lags must be obtained when appropriate.. Information
must be ‘acquired on the child's usual functioning as reported by the
child, parent, teacher, health professional or other knowledgeable
individual.
A
_ The Denver Pre-Screening Developmental Questionnaire (PDQ) or the
abbreviated Denver “Developmental Screening Test (A-DDST) must be
" administered to “children up to age six during the medical screening
visits requiring an objective developmental screening test. - In the event
the child's initial visit does not coincide with. the periodicity
schedule, the PDQ or . A-DDST must be completed at this visit. The
complete Denver Developmental Screening Test (DDST) must be administered
to children who are identified ‘as having possible developmental lags
according to the results ‘of the PDQ or the A-DDST. Other standard
developmental tests may be used if prior approval is received from the
Bureau.
. , :
If the child is suspected of a developmental lag, he or she must be
referred to the local school system's Special Education Child Search
Coordinator.
Developmental screenings should be culturally sensitive and valid.
potential problems- should not be dismissed or excused improperly on
grounds of culturally appropriate behavior. Screenings should not result
in a label or premature diagnosis of child. Providers should report only
that a condition is being referred or that further diagnosis is needed.
Objective developmental screenings must be performed at the following
intervals, at a minimum:
" (a) Two months (or at -the first screening between two months and six
years whenever it occurs) to establish a baseline
(b) Once between nine and twelve months
(c) - Two years: “ges
(d) Three years
(e) Four years
(f) Five years
(g) Six years
Additional developmental screenings may be. scheduled at the parent's
request or if medically indicated as determined by the “screening
provider. Developmental screenings for children over six must be
conducted by consideration of the child's history and by observation.
A11 parts of the standard DOST kit and forms may be ordered from Denver
Developmental Materials, Inc., Post of fice Box 20037, Denver, Colorado
80220-0037, telephone (303)355-4729.
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>
.
c. Physical and Dental Inspection
The child's height (or length), head circumference through age two, and
‘weight must be recorded ‘and compared with those considered normal for
that age. A - comprehensive unclothed physical . inspection primarily
through observation, palpation and auscultation must - be completed at
each screening visit, .for obvious defects or abnormalities including
orthopedic disorders, hernias, skin disease or genital abnormalities or
to identify potential problems for referral. The following body parts
must be evaluated but are :not limited to: .. cranium/face, -hair/scalp,
“ears/eyes, - nose/throat, mouth, teeth, neck, skin, chest/back (for heart
~ and lung disorders using a stethoscope), abdomen, genitalia, muscle tone,
"arms/leg, hands/feet. “Blood pressure and pulse must be measured on all
children three years of age and over at each screening visit, if behavior
permits. Also, general health must be evaluated. =~: gi. ~~.
The inspection ‘must be performed by a physician, physician assistant,
' registered nurse or registered nurse working in expanded roles, e.g.
“certified nurse midwife or certified nurse practitioner. An EPSDT claim
for a medical screening cannot be submitted for reimbursement if an
unclothed physical inspection was not performed.
A dental inspection must be performed on all children at each medical
screening visit. The purpose of this inspection is to look for obvious
dental anomalies, such as dental caries, and to assure access to dental
care for all children. The health history must be reviewed for high risk
factors contributing to dental caries. See Section 2.3.5 for required
dental referral.
d. Immunizations : !
Immunization status must be determined at each medical screening visit to
ensure that every child screened has received primary preventive
immunization against diphtheria, Hemophilus Influenza, pertussis,
. tetanus, polio, measles, mumps and rubella and whether booster shots are
needed. A signed consent must be obtained from the parent(s) or
guardian(s) in order to request immunization status from another health
care provider, They are administered to the child by the medical
screening provider at the same visit as the medical screening, unless
medically contraindicated or if they are not routinely given to patients
by the provider. Immunizations and applicable records must be updated
according to the current immunization schedule of the Louisiana Office of
Public Health or the recommended Schedule of the American Academy of
‘Pediatrics (see figures 2-4 and 2-5). ere ERT
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RECOMMENDED SCHEDULE “ns IMMUNIZATION SCHEDULE
FOR ACTIVE IMMUNIZATION : FOR CHILDREN NOT IMMUNIZED IN INFANCY
OF NORMAL INFANTS AND CHILDREN
: : UNDER 7 YEARS OF AGE 7 YEARS OF AGE AND OVER
AGE | 1 snl miels3 6 7
rs 1 2. FIRST VISIT: DTP® TOPY® MMR™’ FIRST VISIT: Td~ TOPY MMR
2 MONTHS OTP TOPY “ls
4 MONTHS, OTP TOPY : Interval after first visit: Interval after firgt visit:
6 MONTHS® DTP 3 « 2 Months later DTP TOPY 2 Months later Td, TOPV
15 MONTHS DTP TOPY MR”, HIB 2 Months later DTP 6-12 Months later Tdg TOPV
4-6 YEARS OTR TOPY 6-12 Months later OTP TOPY 14-16 Years of Age Td” Repeat every
14-16 YEARS Td Repeat every 15-59 Months of age HIB 9 10 years
OF AGE 10 years 4-6 Years of age OTP TOPY
or Preschool 6
14-16 Years of age Td” Repeat every
10 years
1) OTP - Diptheria and tetanus toxoids combined with 6) Td - Combined tetanus and diptheria toxoids (adult type)
Pertussis.
for those 7 years of age and older.
2) TOPY - Trivalent oral polio virus. 7) Measles vaccine, rubella vaccine, and mumps vaccine may
be given at the first visit along with DTP, Td or OT and
3) MMR - Can be given any time child come to clinic TOPY; this is useful if provider is concerned about
after 15 months of age. If child was vaccinated return visit 1 month after first or if more rapid
before 12 months of age, give second injection. protection against measles, mumps, or rubella is desired.
. (Check with Health Department for current recom-
mendation for 2nd MMR dose.)
4) HIB will be given at 15 months up to 60 months of 8) If initiated in the first year of life, give pTP-1, 2,
age.
and 3, TOPY-1 and 2 according to this schedule and then
. give MR when child becomes 15 months old.
5) Give OTP and T0PY after 4th birthday, but before
or at the time of entering school. : 9) The preschool dose is not necessary if the 4th dose of
OTP and 3rd dose of TOPY are administered after the 4th
a DTP and Polio can be given at 6-8 week intervals. birthday.
Louisiana Office of public Health Childhood Iemunization Schedule
Figure 2-4
Immunization Schedule (A)
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
AMERICAN ACADEMY OF PEDIATRICS
RECOMMENDED SCHEDULE FOR ACTIVE IMMUNIZATION OF NORFAL INFANTS AND CHILDREN
RECOMMENDED [MMUNTZATION(S)® COMMENTS
AGE
2 mo DTP, OPV Can be initiated as early as
age 2 wk in areas of high
endemicity or during
epidemics
MOTE in =0TP, PY" @ ~~ -2-m0. interval desired for
5 a ade OPV to avoid interference
; Love 8 from previous dose -
. 6 mo : DTP : Hd A third dose of OPV is not
indicated in the U.S. but
is desirable in geographic
areas where polio is
: endemic 2
15 mo Measles, pa MMR preferred to individual
mumps, vaccines;
rubella
(M43)
DTP
PRP-D
18 mo - opv3 : See footnotes
4-6 yr pTp,? OPV At or before school entry
11-12 yr MMR? See footnotes
14-16 yr Td | _ Repeat every 10 yr throughout
life
1 DTP = diptheria and tetanus toxoids with pertussis vaccine; OPV = oral
poliovirus vaccine containing attenuated poliovirus types 1, 2, and 3; MMR
= live measles, mumps, and rubella viruses in a combined vaccine PRP-D =
Hemophilus b diphtheria toxoid conjugate vaccine; Td = adult tetanus toxoid
(full dose) and diphtheria toxoid (reduced dose for adult use.)
a Should be given 6 to 12 months after the third dose. May be given
simultaneously with MMR at age 15 months.
3 May be given simultaneously with MMR at 15 months of age or at any time
between 12 and 24 months of age.
4 yp to the birthday age 7.
5 Check with “Red Book."
Figure 2-5.
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Laboratory Screening Procedures’
"Laboratory screening procedures’ must be done in coordination with other
medical screening services at the same visit, whenever -possible. If
there is written documentation or notification from another provider that
"any required ‘laboratory procedure was performed less than three months
prior to the screening visit and there is no indication of a need for a
redetermination of the test result, it~ is not necessary to perform the
test again. _ Tibet ag 10 BER REE RS TR Na Taye SA St
a is oi TRL;
# WE
_{1)". Metabolic Screening fartiumenr Eonietu s 2 Gopi
“PKU and hypothyroid screening tests should be performed during one
"of the neonatal visits before the child is one month old and in
compliance with state law. These tests must be performed during the
initial screening visit between birth and one year of age, if there
is no record of the tests having been performed previously during
one of the neonatal visits. Children over age one need only be
screened when medically indicated. A |
(2) Sickle Cell Disease Screening
Sickle cell screening is required at the initial medical screening
visit between birth and one year of age on all children of mothers
who indicate their racial group as black unless the mother has
documented negative test results. Sickle cell screening should be
performed, if possible, on or before the two month screening. This
screening should not be performed after age one unless medically
indicated or at the parent's request.
(3) Iron Deficiency Anemia Screening
Hematocrit or hemoglobin values must be determined at the medical
screening visit at either nine months or 12 months of age and again
at the screening “visit at two years of age. Hematocrit or
hemoglobin values must be determined during all subsequent medical
screening visits from age two to age 21.
(4) Urine Screening
Urine screening must be performed at the medical .screening visit
‘between birth and two years of rage, between two and five years of
age, between five and 12 years of age, and between 12 and 20 years
of age, depending on the success in obtaining a .voided urine
" specimen. © The required ‘screening method is a dipstick that shows
“the measurement of pH, protein, blood, and glucose and detects the
presence of leukocytes and nitrite in the urine.
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(6) Other Tests
(5) Lead Toxicity Screening
Screening .for lead toxicity must be performed annually at each
medical. screening visit on children ages one through five by an
,... Erythrocyte Protoporphyrin (EP) test. .The EP blood sample must be
=m az-collected ,via a finger stick or. venous sample and mailed or
. -...delivered to a laboratory approved by the Bureau. A blood lead test
--~:must be performed on children with EP results equal to or greater
than 35 micrograms per 100 milliliters of blood, and when indicated
by the presence of high risk factors for lead toxicity. = If the
blood lead is elevated, the medical screening provider must also
arrange for medical and environmental follow-up. ~~ Environmental
~usfollow-up can be arragned with the local health department on any
child with an elevated lead level . in accordance with the current
~~ Centers for Disease. Control (COC) guidelines . for screening.
Children age six and over should be screened for lead toxicity only
when medically indicated. --. - a an :
- J RE
There are several other tests to consider in addition to those
listed above. Their appropriateness is determined by an
individual's - age, sex, health history, clinical symptoms and
exposure to disease. These may include, for example, tuberculin
test, a pinworm slide, urine culture (for girls), and stool specimen
for parasites, ova and blood.
" Nutritional Status Screening
Nutritional status must be assessed at each medical screening visit.
Screening must be based on dietary history, physical observation, height
(or length), weight, head circumference (ages two and under), EP values
(age one "to six), hematocrit/hemoglobin and the other laboratory
determinations -carried out in the medical screening process.
Cholesterol determination should be performed, if indicated by history or
inspection findings. :. ~~. ; wk rE wh, :
Health Education
This includes individual or group health education, individual
anticipatory guidance and individual . interpretive conference. Health
education and counseling to both parent(s) or guardian(s) and the youth
(if age appropriate) is required at each medical screening visit. It is
designed to : assist the parent(s), or guardian(s). and/or youth in
understanding what to ‘expect in terms of the child's development and to
‘provide : information about the benefits of healthy lifestyles and
practices as well as accident and disease prevention.
Health education must be age appropriate, culturally sensitive, and
geared to the particular child's medical, developmental and social
circumstances. A list of age-related topics recommended for discussion
at screenings is included in the appendix to this manual. This should be
viewed as a guideline only. It should not be seen as requiring the
inclusion of topics which are inappropriate for the child or limiting the
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(5) Lead Toxicity Screening
screening for lead toxicity must be performed annually at each
medical screening visit on children ages one through five by an
Erythrocyte Protoporphyrin (EP) test. The EP blood sample must De
collected via a finger stick or venous sample and mailed or
delivered to a laboratory approved by the Bureau. A blood lead test
must be performed on children with EP results equal to or greater
than 35 micrograms per 100 milliliters of blood, and when indicated
by the presence of high risk factors for lead toxicity. If the
blood lead is elevated, the medical “screening ‘provider must also
arrange for medical and environmental follow-up. Environmental
follow-up can be arragned with the local health department on any
child with an elevated lead level in accordance with the current
-Centers for Disease Control (CDC) guidelines ~ for screening.
Children age six and over should be screened for lead toxicity only
when medically indicated. pk atl SEIT Hl AE:
Other Tests
There are several other tests to consider in addition to those
listed above. Their appropriateness js determined by an
individual's age, Sex, health history, clinical symptoms and
exposure to disease. These may include, for example, tuberculin
test, a pinworm slide, urine culture (for girls), and stool specimen
for parasites, ova and blood.
Nutritional Status Screening
Nutritional status must be assessed at each medical screening visit.
Screening must be based on dietary history, physical observation, height
(or length), weight, head circumference (ages two and under), EP values
(age one to six), hematocrit/hemoglobin
and the other laboratory
determinations carried out in the medical screening process.
Cholesterol determination should be performed, if indicated by history or
inspection findings. : i
: :
Health Education
‘This includes "individual
h education, individual
anticipatory guidance and
Health
education and couns
. (if age appropriate) is requir
designed to . assist the parent(s),
understanding what to expect in terms of the ch
provide information about the benefits of - healthy
. practices as well as accident and disease prevention.
Health education must be age appropriate, culturally sensitive, and
geared to the particular child's medical, developmental and social
circumstances. A list of age-related topics recommended for discussion
at screenings is included in the appendix to this manual. This should be
viewed as a guideline only. It should not be seen as requiring the
(es) pty ph 01E 7
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual is
Three or four years (depending on whether the child is testable at three)
Five years
Six years . .. .
Eight years
Ten to 12 years
-14 years
2716 ©0. 18 years:
+= 20 years
2.3.3.2 Vision Screening Components Ea a Pi 3
A subjective screening for visual problems must be performed on children from
birth ;to -age ‘three or four by history and” observation. History includes
information on the family's and the child's history of eye disorders, systemic
diseases having eye involvement or affecting vision," behavior indicating risk
of eye problems or whether the child is currently under care for an eye
condition. Observation includes external scan, assessment of visual response
(fixation and pupillary reflexes) and muscle balance as defined below:
a. External scan
(1) Cornea - clarity .
(2) Pupils - size, shape, equal, reactive
(3) Iris - color, abnormality of shape, size
(4) Conjunctiva and lids - sign of inflammation or infection, tumors,
chronic tearing, ptosis (squint), trauma
Visual response
(1) Pupillary reflex - response to penlight
(2) - Fixation - central and steady
Muscle balance %
(1) Convergence - within 6 inches of the nose
(2) Eye alignment - light reflection center in each eye (Hirschberg
test) .-. | ; chil
(3) Alternates freely and fixes steadily with either eye
(4) Tracking - follows penlight in all direction equally with each eye
Objective testing must begin at age three (if the child is testable) or four
(if the child is not testable at three). Objective testing must include
visual acuity, color perception and muscle balance. Visual acuity screening
must be performed through the use of the Snellen Test, Allen Cards, or their
‘equivalent. These methods must be’ used for all ‘objective testing visits
‘listed in the periodicity schedule and more often, if medically indicated.
Muscle balance assessment including .all the components listed -above must be
done at each visit listed as objective in the periodicity schedule and more
often, if medically necessary. Color perception screening must be performed at
least once using polychromatic plates by Ishihara, Stilling or Hardy-Rand-
Ritter. oom ; bi
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EPSDT Services Provider Manual
2.3.3.3 Vision Screening personnel
Vision screening must De performed by one of the following health
professionals: physicians; physician assistants; registered nurses; certified
pediatric and family nurse practitioners; and optometrists. - All vision
screening personnel must work within professional licensing criteria. Eo
2.3.4 Hearing Screening
TET
2.3.4.1 “Hearing Screening Periodicity Schedule ..
Hearing providers must screen children as soon as possible, but no later than
60 days the date of the request for an initial screening on children under two
years and 120 days from the date of the request on children age two and older.
The purpose of the hearing screening is to detect hearing impairments,
presence of ‘congenital abnormalities or history of conditions which may
increase the risk of potential hearing loss. (Objective screenings, using
recognized testing methods, must be performed in accordance with the schedule
given below. These screenings must be done concurrently with the medical
screening and at the same visit, whenever possible. Hearing screening by
history and observation is a required part of the physical
examination/assessment at each screening visit in which an objective screening
is not mandatory. Objective hearing screenings are required at the following
intervals:
a. Age three or four (depending on whether the child is testable at three)
b. Five years
Ce Six years
de Eight years
e. Ten to 12 years
f. 14 years
g. 16 to 18 years
h. 20 years
2.3.4.2 Hearing Screening Components
A subjective screening for hearing problems must be performed on children from
birth to age three or four by history and observation. Observation must
include screening for congenital abnormalities of the ear, head and neck and
response to voice and other external auditory stimuli. ~ History must include
questions ‘about the child's -response to voices and other auditory stimuli;
delayed speech development; chronic or current otitis media or other health
history which places the child at risk of hearing loss or impairments. ° 4
Objective hearing testing begins at age three (if the child is testable) or
four. Hearing screening must be performed through the use of a pure tone
audiometer at 500 and 4,000 Hz at 25 decibels for both ears. If the child
fails to respond at either frequencies in either ear, a complete audiogram
must be done. This audiometer must be calibrated annually or more often, if
indicated. ~ This method is used for each visit listed in the periodicity
schedule above and more often, if indicated.
hs!
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual = ~*~ °
2.3.4.3 Hearing Screening Personnel
Hearing screening must be performed by one of the following health
professionals: physicians; physician assistants; registered nurses; certified
pediatric and family nurse practitioners -and audiologists. All hearing
screening personnel must work within professional licensing criteria. ;
2.3.5 Dental Screening
A direct referral to a licensed dentist for a complete dental examination must
begin no later than age three “and must -be made earlier, if medically
indicated. These screenings must continue at yearly intervals until the child
reaches age 21. * The medical ‘screening provider must make the initial direct
referral to a Medicaid enrolled dentist of the recipient's choice. Follow-up
on the initial referral to -assure ‘that the referred ‘child gets to the
dentist's office (within 60 days) is part of the medical screening provider's
care . coordination responsibility. : The dental provider is responsible for
annual follow-up after the initial dental screening examination. The medical
screening provider must determine ‘at subsequent medical screenings after the
initial direct referral to dentist that the child has received a dental
examination in the previous 12 calendar months. If the child has not received
dental services, the medical screening provider must refer the child to a
dentist of his/her choice and assure that the child receives an annual dental
examination. Refer to the EPSDT Dental Services Manual for dental services
covered, procedures to be followed by the dentist and dental billing
instructions.
2.3.6 Care Coordination
Providers of medical screening services are responsible for overall care
coordination. These ongoing activities include locating, scheduling,
coordinating, following up and monitoring necessary EPSDT screening and other
health services. Care coordination enhances EPSDT Program efficiency and
effectiveness by assuring that needed services are provided in a timely and
efficient manner and that duplicated and unnecessary services are avoided.
2.3.6.1 Scheduling Screenings and Follow-up
Medical screening providers must maintain an adequate system of controls to
assure that the medical screenings are performed in a timely manner 60 days
from the date of the request for services on children under age two and 120
days from the date of the request on older children.’ Notifying EPSOT -eligible
children when they are due to receive a medical screening and making an
appointment for that child for the next screening in the periodicity schedule
are integral parts of the complete medical screening provider's responsibility
and essential parts of care coordination. ou oe Be
It is the responsibility of the vision, “hearing or dental screening provider
to contact the child to schedule the next screening visit on the periodicity
schedule in his or her specialty. ‘The vision or hearing screening provider,
upon obtaining a properly executed consent form from the parent(s) or
guardian(s) must notify the child's medical screening provider of screening
results, date screened and referral information, if applicable, within 60 days
of the screening.
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2.3.6.2 Scheduling Diagnosis, Treatment and Follow-up
If ‘a condition requiring further diagnosis, treatment and/or other health
services 1S detected in the screening, it is the responsibility of the
medical, vision, hearing or dental screening provider to:
a. Determine what resources a child needs and to which provider he or she
wishes to be referred (the recipient's freedom of choice of providers
must be ensured);
oF, hE
b. Make the appropriate referral in a timely manner;
c. Offer and provide, if requested and necessary, assistance in scheduling
the appointment; Tony bier THEE fy ;
d. Verify whether the child received the service;
e. If the child missed the appointment, make a second “good faith" effort to
get the child to the medical facility. Contact the family by telephone
or mail and document this in the child's health record. A two-day notice
is required to arrange transportation to the appointment through the
local OFS;
It is the medical screening provider's responsibility to assure that medically .
necessary diagnosis, treatment and other health related services are initiated °
within 60 days of the medical, vision or hearing screening. The provider must
notify the medical screening provider of services provided, dates and the
results of services provided upon obtaining a properly executed consent form
from the parent(s) or guardian(s).
EPSOT screening services cannot be terminated for a child solely because he
has failed to keep a screening appointment. The family must always be
notified when the next periodic screening is due, regardless of attendance at
_ previous screenings.
si
2.3.6.3. Referrals Between Health Units and Local School Systems
Local health units and participating EPSDT Nursing Programs in local school
systems are required to coordinate screening "services to EPSDT eligible
children to reduce duplication and fragmentation of. services. Their
responsibilities include the following: pai b ro
a. -Enter into local interagency agreements coordinating EPSOT services
including delineating specific agency responsibilities and procedures;
b. The school nurse must provide the name, Medicaid number and date of birth
in requesting information on Medicaid eligible children for whom the
school nurse is assuming screening responsibility from the health unit.
The local health unit, must provide each school nurse with the following
information on a maximum of 20 children within 10 working days of the
request by the school nurse: | :
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) Date of last medical, vision and hearing screening
) Immunization status (with properly signed parental consent form)
) Date and results of last lead poisoning screening
) Health problems requiring follow-up :
2.3.6.4 Transportation Services
To ensure that the child obtains needed screening, diagnosis, treatment, and
other health services, the screening provider must offer and provide, if
requested and necessary, assistance with transportation prior to each due date
of a child's initial and .periodic screening and other medically necessary
appointments. The child's parent(s) or guardian(s) must be referred by
telephone “to the parish. OFS _at least .48 “hours before the scheduled
appointment. The parish office is responsible for arranging transportation,
if needed, for the child to receive health services. TA 2
2.3.7 Other Preventive Health Care
The provider may provide other health care services or refer the child to
another provider for other health care which in the provider's medical
judgment are appropriate to the child's age, sex, health history, clinical
assessment and exposure to disease. These health services may include but are
not limited to:
a. Tuberculosis testing
b. Pinworm slide
c. Urine“culture (for girls)
d.” Serological test
e. Drug dependency screening
f. Stool specimen for parasites, ova, and blood
g. Pregnancy test
h. HIV screening
i. Family planning services
j. Prenatal care services
k. Other immunizations
1. Speech and language screening
$ 2.3.8 ~~ Screening Documentation Requirements
All screening providers must make the health and billing/payment records of
all EPSDT-eligible children available to the Bureau and other state and
federal agencies upon request as provided in Section 1.4.2. : ae
All medical screening providers must maintain complete health records for at
least three years on all children screened, which include at’ least the
following: *© ~- ° a” ae
a. Documentation of the date of recipient acceptance of screening services.
School nurses must. document the date the signed parental consent form for
‘screening services is received. Other providers must document in the
child's health record the date of initial contact with the parent(s) or
guardian(s) to request or accept an appointment for screening the child;
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b. Documentation of the completion of a screening and other medically
necessary services, tests given, test results and the dates the service
was performed and the health care provider;
Gr If a required screening component was not completed, documentation of the
reason that it could not be completed; ;
d. If the child failed to attend the medical, vision, hearing or dental
screening, documentation of “good faith" efforts to schedule a second
screening within the periodicity requirements; :
e. Documentation of the completion of the appropriate screening or other
health service claim form for allowable services; .-. -
f. The date the child is to be rescreened (periodicity);
g. Documentation of referral(s) for diagnosis, treatment and other health
services, including dates and results of these services. Referral data
and suspected conditions (no more than six) must be reported on the
screening claim form; a : :
h. Documentation of the source of the request for an interperiodic screening
and medical necessity;
i. Other documentation of health services provided, care coordination
provided and copies of referral forms;
2.3+9 Reimbursement for Screening Services
Medical screening providers are reimbursed on a fee-for-service basis by the
Bureau for a complete screening provided to a Medicaid eligible child which
includes all of the age appropriate requested services and procedures '
described in Section 2.3.2 (e.g., comprehensive health and developmental
history, unclothed physical and dental inspections, immunization status,
-laboratory procedures and health education). Timely filing limitations for
EPSDT screening will be 60 days from date of service effective October 1,
1990. All EPSDT screeners must bill electronically. :
A physical and dental inspection must be performed in order to bill for a
medical screening. Required laboratory procedures cannot be billed separately
from the screening. A confirmatory EP test or blood lead test may be billed
separately. The medical screening fee does not include vision or hearing
screening, immunizations or other medically necessary diagnosis, treatment
and other services. Care . coordination :as defined in Section 2.3.6 and
administrative overhead are also covered in the medical screening fee. Claims
for regularly scheduled medical screening services must be submitted only on
the EPSDT Screening Services Billing Form 107. Interperiodic screenings
cannot be billed on the EPSDT Screening Services Billing Form 107. They must
be billed as preventive office visits (CPT codes 90760-90764). Refer to
Section 3.1.1 for the specific form instructions and reporting requirements.
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EPSDT Services Provider Manual Be iA
Vision and hearing screeners are reimbursed separately from .the medical
screening fee on a fee-for-service basis by the Bureau for age appropriate
objective vision services and hearing screening
and 2.3.4. Subjective sensory screening is an
described in Sections 2.3.3
integral part of the health
history and physical inspection and is, therefore, - not reimbursable as a
separate fee. Claims for objective vision, objective hearing and immunization
services must be submitted separately using the HCFA Claim Form 1500. Refer
to Section 3.1.2 for the specific form instructions. . Immunizations are also
reimbursed on a fee-for-servi ce basis according
given.
an Te Re EL PE
Procedure codes and fees for medical, vision and
to the type of immunization
hearing screenings are listed
below. These services should be provided *according to the appropriate
periodicity schedule or as medically indicated.
Procedure Code Fee Description
$ (X9000) 17" 460,00: Complete medical screening by a physician or
physician assistant :
I (X9002) $60.00 Complete medical
: : nurse, certified
screening by a registered
nurse midwife or certified
5d pediatric or family nurse practitioner
X0500 $60.00 Initial-reopen- annual family planning visit
90225 $60.00 History and examination of newborn (prior to
hospital discharge) -
X9007 $ 4.00 Objective vision screening
92551 $ 4.00 Objective hearing screening
See EPSDT Dental Services Provider Manual for
dental services.
instructions on billing for
2.3.10 Reimbursement for Other Preventive Health Care
Screening providers may be reimbursed for other covered health services which
-are not provided as part of th e screening package. Consultations, counseling
and follow-up services may be delivered by professional staff (registered
nurse, physician, nutritionist, social worker, etc.). These services, fees
and applicable procedure codes are listed below. Service contacts or
interventions must be face-to-face to be billed. :=.: B
Interperiodic Screening - See definition in Section 2.3. Interperiodic medical
screenings must include a physical inspection, health and history update and
other appropriate procedures. Interperiodic vision and hearing screenings may
be billed using procedure codes X9007 and 92551. :
Procedure Code Fee ~ Description -:
90760-90764 5 $37.00 Interperiodic medical screening by a physician
or physician assistant (Use appropriate CPT
se "preventive office visit code)
Xo004 $27.00 Interperiodic medical screening by a registered
nurse
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual : !
IMMUN [ZATIONS
effective July 17, 1990 the following immunization codes have been added for
payment for EPSOT providers. Payment for these codes is as follows:
~
Procedure Code fee Description
90701 $ 18.00 Immunization, Active; (DTP) -
90703 = -"¢ ; 5.07 .--. Tetanus Toxoid = ~ os -
90702 =~ _.~ +:5.00 - -.Diphtheria and Tetanus Toxoids (DT)
90704 22.00 Mumps Virus Vaccine, Live
90705 #2. 22.00 . :- Measles Virus Vaccine, Live, Attenuated
90706 ~~ -22.00 - Rubella Virus Vaccine, Live fod
90707 35.00 Measles, Mumps and Rubella Virus Vaccine, Live
90708 +L wie RE. 138.0008 Measles and Rubella Virus Vaccine, Live
go709 Txasiiienr 238.00 - Rubella and Mumps Virus Vaccine, Live
90712 18.00 Polio Virus Vaccine, Live, Oral (Any Type(s))
90713 18.00 Poliomyelitis Vaccine
90714 5.00 Typhoid Vaccine
90717 5.00 = Yellow Fever Vaccine
90718 12.00 igus and Diphtheria Toxoids Absorbed, Adult
TD
90719 5.00 Diphtheria Toxoid
90724 12.00 Influenza Virus Vaccine
90725 5.00 Cholera Vaccine
90731 18.00. Hepatitis B Vaccine
90732 + 22.00 Pneumococcal Vaccine, Polyvalent
90737 22.00 Hemophilus Influenza B
Speech and Language Screening
This must be performed by a physician, physician assistant, registered nurse,
certified nurse practitioner or licensed speech pathologist. Tasks or test
used in the screening must include the following:
a. Auditory processing skills (e.g.,reception, discriminate
b. Articulation :
c. Receptive and expressive language
d. Voice
e. Fluency
f. Oral motor functioning
g. Oral structure
Procedure Code Fee Description
X0401 $4.00 Objective speech and language screening
Consultation, Counseling or Follow-up Service - This may involve, but is not
limited to, counseling the child and/or parent(s) or guardian(s) regarding a
condition found as a result of screening, or consulting with a teacher, social
worker, physician or other professional regarding a condition detected.
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EPSOT Services Provider Manual
Nurse consul tation Consol to, intervention or follow-up services for a
condition found during a screening cannot be billed on the same day as a
physician office visit for diagnosis and/or treatment. Consultation,
counseling or follow-up services provided by a registered nurse, social worker
or nutritionist on the screening date may only be reimbursed for conditions or
problems resulting from the screening. A referrable condition and suspected
condition(s) must be indicated on the screening form. |
Procedure Code. Fee ¢ Description Hetil PELE ny
X0187 315.71 Consultation, - Counseling, Intervention ‘or
| ~Follow- Up. Service by a Rag) stared Nurse Sah
X0188 Pe ETE $15.71 ‘Consultation, Counseling or Follow- Up Service by
Pay a HL Licensed Dist ician/Nitritionsst Eas
X0189 j i “$15.71 : CoRdil tition, Counseling or Follow- Up Service by
ae fe an MSW-Social Worker For. a Condition Detected in
‘the Screening 5 iF ge
X0194 $31.42 Lead Poisoning Screening Environmental Follow-
Up - Environmental inspection by a sanitarian to
determine possible lead source of children
identified with or at risk of developing lead
poisoning
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2.4 EPSDT DIAGNOSIS AND TREATMENT
One of the primary purposes of the EPSDT services is to assure that health
problems are diagnosed and treated early bafore they become more complex and
their treatment more costly. An EPSOT child is eligible to receive any
medically necessary health care, diagnosis, treatment and other health
services to correct or ameliorate defects and physical and mental illnesses
and conditions that have been discovered or shown to have _increased in
severity by the screening services. = These services may include any of the
mandated or optional services listed in Section 1.6. Some of these services
require prior. authorization of the Bureau or its designee to make the
determination of medical necessity. = A Hr - [pms ~2
2.4.1 Diagnosis
[f, as a result of a medical, vision, hearing or dental screening, it Is
suspected or confirmed that the child has a physical or mental problem, the
screening provider must refer the child without delay for further . evaluation
of the child's health status and follow-up to assure that the child receives a
complete diagnostic evaluation. Diagnostic services may include but are not
limited to physical examinations, developmental assessments, psychological and
mental health evaluations, laboratory tests and x-rays. Diagnosis may be
provided at the same time as the screening or it may be provided at a second
appointment. Diagnosis may or may not require further follow-up and referral .
for treatment. The child must be referred for a physical examination
performed Dy a physician .if the child is screened by a non-physician and there
is reason to believe that the child has a medical problem requiring the
diagnostic services of a ‘physician. The child must be referred for
developmental assessment, psychological, mental health and/or evaluation for
special education services if indicated by developmental delays, history of
poor school performance, poor social adjustment and emotional or behavioral
problems. Diagnostic services must be initiated within 60 days of the
screening.
2.4.2 Treatment
The screening provider must also refer a child within 60 days of the screening
for medically necessary treatment and other services to correct or ameliorate
the physical and mental problems found in the medical, vision, hearing, and
dental screening. = Treatment may include but is not limited to physicians’ or
dentists' services, optometrists’ ‘services, podiatrists services, hospital
services (inpatient and outpatient), clinic services, laboratory and x-ray
services, prescribed drugs, eyeglasses, hearing aids, prostheses, physical
therapy, rehabilitation services, psychological services and other types of
health care and mental health services. (See list in Section 1.6) Treatment
services must be initiated within 60 days of the screening.
Dental services include emergency, preventive and therapeutic services as well
as orthodontic treatment when medically necessary. :
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2.4.3 Reimbursement
Physicians and physician assistants may be reimbursed for medically necessary
diagnosis and/or treatment ‘provided on the screening date or other date.
Providers can only bill for limited office visit or appropriate lower level
of fice visit for diagnosis and/or treatment provided on the screening date. -
2.4.4 Sources he
Diagnosis and treatment services may be provided by the screening provider or
may be obtained by referral to any of the sources listed below. - The family's
right to choose the public or private provider must be maintained. SAS
a. Physician
b. Dentist
c. Health department .. ..
d. - Community health center Zh rd (ink of Bras
e. _ Local school system special education department (e.g., child search)
f. . Hospital outpatient department : : : 2rd
g. Rehabilitation Center
h. Psychologist
; 3 Social worker
j. . Community mental health center
k. Substance abuse. treatment center
1. -Other practitioner or facility qualified to evaluate, diagnose or treat
the child's health problem.
2.4.5 Health Services for Children with Special Needs
The Louisiana Medical Assistance Program provides for coverage of screening,
evaluation, diagnosis and treatment of handicapped children and children
receiving health-related special education services within the framework of
the EPSDT services.
2.4.4.1 Legal Basis
Public Law 94-142, Part B of the Education to the Handicapped Act, originally
passed by Congress in 1975, mandates that all handicapped children ages five
to 21 receive a free and appropriate public education within the least
restrictive environment and assistance with health problems associated with
‘their disabilities as needed while in school. The Senate Report on Public Law
94-142 states -that “...any funds available from ‘the federal government
(Medicaid) are clearly in addition to funds provided under this Act and are
available to states to assist them in carrying out their responsibilities...”
‘As amended by Public Law 99-457 in 1986, Part B authorized a preschool grant
program to support the same services to handicapped children ages three to
five. The 1986 statutory amendments to Part B further clarified the role of
Medicaid and other sources in financing Individual Education Plan (IEP)
related services. Fly : i
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states are prohibited from using Part B funds to satisfy a financial
commitment for services that would be paid for by other federal, state,
and local agencies;
:
Public Law 94-142 cannot be construed to permit a state to reduce medical
or other ‘assistance available or alter Title V or Medicaid eligibility
with respect to the provision of a free and appropriate public education.
The 1986 amendments to the Education to the Handicapped Act also established
the Part H program. = Part H of Public Law 99-457 authorized the Secretary of
Education ‘to make formula “grants available to states for the purpose of
planning and implementing coordinated systems of early intervention services
for children from birth to “age three. The ‘Louisiana Department of Education
is the lead agency responsible for coordinating the full implementation of
Part .H of Public Law 99-457, the Handicapped Infants and Toddlers Program.
Act 377 of Part III of Chapter 8 of Title 17 of Louisiana Revised Statutes of
1950 establishes the Louisiana Handicapped ‘Infants and Toddlers Program for
the Early Intervention of Infants and Toddlers with Handicaps. This act also
establishes the program goals of assuring that the statewide system will be in
effect which will include multi-disciplinary assessments, individualized
family service plans, and case management services. :
The Part H grant program for early intervention services contains two
statutory provisions which defines the intent of Congress related to financing .
these services.
:
- The grant funds may be used to fund direct services only if these
services are not otherwise provided by private or other public sources
(Medicaid), or if they are available but need to be expanded or improved;
States are expressly prohibited from using grant funds to reduce medical
or other available assistance or to alter eligibility under Medicaid and
the MCH Block Grant programs. Ep
Congress reinforced Medicaid's availability to pay for early intervention and
preschool special education services through a Medicaid amendment included in
the Medicare Catastrop The amendment clarified that
prohibiting or
restricting payment
Plan because they are prov
pursuant to an individualized
family service plan (IFSP).
responsible for. special instructions and educa
children. The state Medicaid agency is respons
related services to these children to the extent
its State Plan.
More recent changes in the Medicaid statute have greatly expanded the Medicaid
program's role as a financier of health related early intervention and special
“education services for Medicaid - eligible children. The Omnibus Budget
Reconciliation Act of 1989 (OBRA-89) extends Medicaid eligibility to more
children and directs states to provide expanded benefits for all medically
necessary children's services. These expanded EPSOT benefits mandated under
OBRA-89 have made Medicaid an increasingly important financing resource for
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- States are prohibited from using Part B funds to satisfy a financial
commitment for services that would be paid for by other .federal, state,
and local agencies; X
_ public Law 94-142 cannot be construed to permit a state to reduce medical
“or other assistance available or alter Title V or Medicaid eligibility
with respect to the provision of a free and appropriate public education.
The 1986 amendments -to .the:- Education to the Handicapped Act also established
the Part H program. : Part H of Public Law 99-457 ‘authorized the Secretary of
Education to make ~formula -grants available to states for the purpose of
planning and implementing coordinated .systems of early intervention services
for children from birth to age three. The Louisiana’ Department of Education
is the lead ‘agency responsible for coordinating the full implementation of
Part H of Public Law. 99-457, the Handicapped Infants and Toddlers Program.
Act 377 of Part III of Chapter 8 of Title 17 of Louisiana Revised Statutes of
1950 establishes the Louisiana Handicapped Infants ‘and Toddlers Program for
the Early Intervention of Infants and Toddlers with Handicaps. This act also
establishes the program goals of assuring that the statewide system will be in
effect which will include multi-disciplinary assessments, individualized
family service plans, and case management services.
The Part - H grant program for early intervention services contains two
statutory provisions which defines the intent of Congress related to financing
these services.
- The grant funds may be used to fund direct services only if these
services ‘are not otherwise provided by private or other public sources
(Medicaid), or if they are available but need to be expanded or improved;
- States are expressly prohibited from using grant funds to reduce medical
or other available assistance or to alter eligibility under Medicaid and
the MCH Block Grant programs. SES
Congress” reinforced Medicaid's availability to pay for early intervention and
preschool special education services through a Medicaid amendment included in
the Medicare Catastrophic Coverage Act of 1988. The amendment clarified that
nothing under the Medicaid statute .is to be construed as prohibiting or
restricting payment for :services ordinarily covered under a Medicaid State
Plan because they are provided to a handicapped infant, toddler, or child
pursuant to an individualized education program (IEP) or an individualized
family service plan (IFSP). .. The state education” "agencies ‘are therefore,
responsible for special ‘instructions. .and education services to handicapped
children. The state Medicaid agency is responsible for reimbursing health-
related services to these children to the extent the state covers them under
its State Plan. i BY a rigs
More recent changes in the Medicaid statute have greatly expanded the Medicaid
program's role as a financier of health related early intervention and special
education services for Medicaid - eligible children. ~The Omnibus Budget
Reconciliation Act of 1989 (OBRA-89) extends Medicaid eligibility to more
children and directs states to provide expanded benefits for all medically
necessary children's services. ‘These expanded EPSDT benefits mandated under
OBRA-89 have made Medicaid an increasingly important financing resource for
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2.4.4.3.1 Evaluation Services
These services include evaluation and re-evaluation services. The fee covers
the service and necessary evaluation coordination services. Use of assessment
tools and guides not listed in this section requires prior approval of the
Bureau.
Physical Therapy (PT) Evaluation - includes testing of gross motor skills,
functional orthotic and/or prostetic evaluation : and performing and
interpreting tests “and measurements of neuromuscular, musculoskeletal,
cardiovascular, respiratory and sensorimotor functions. : These services must
be provided by an individual licensed in Louisiana to provide physical therapy
services in Louisiana. ‘These services must include the following:
1. Muscle testing, manual, extremity or trunk, with report .
2. Total physical therapy evaluation of body ! :
3. Range of motion measurements and report on each extremity, excluding
hand
4. Range of motion measurements and report
Standard assessment tools and informal assessment guides used -must be from
those listed below. Informal methods, including observation of behavior
during the evaluation and supplemental testing may also be used.
Pediatric Screening: A Tool for Occupational and Physical Therapists
Joint Range of Motion Test :
Berry Development Test of Visual-Motor Integration (VMI)
The Macquarrie Test for Mechanical Ability
Early Intervention Developmental Profile (EIDP)
Preschool Development Profile (PDP)
Motor Free Visual Perception Test
Denver Developmental Screening Test
Manual Muscle Tests ;
Southern California Sensory Integration Test (SCSIT)
The Miller Assessment for Preschoolers (MAP) .
The Developmental Test of Visual Perception (Frostig)
m. Test of Visual Perceptual Skills (TVPS) ary
n. Bruininks-Oseretsky Test of Motor Proficiency .
0. Bayley Developmental Scales
Pe Callier-Azusa Scale : a2
q. Bender Visual Motor Integration Test - .
re Errhardt Developmental Test of Visual Perception
S. Frostig Developmental Test of Visual Perception
t. Gesell Developmental Schedules | :
ue. McCarthy Scales of Children's Abilities
Ve Milani-Compareth
We North Carolina Curriculum
Xe Perceptual Motor Screening
y. Purdue Perceptual Motor Survey
z. Reflex Testing Methods of Evaluating Central Nervous System Development.
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Procedure
Code fee Description
X0410 154.00 Physical Therapy (PT) Evaluation
Occupational Therapy (OT) Evaluation - includes tasks, items or tests used to
evaluate problems interfering with functional performance in a child impaired
by physical illness .or injury, ~emotional disorders, congenital or
developmental disabilities. : These services must be provided by an individual
licensed in Louisiana to provide occupational therapy services. Such services
must include the following: ~ "+ eh ; : : abe
i. Occupational Therapy sEvaluation of muscle tone, . movement patterns,
reflexes and fine motor/perceptual motor development utilizing
assessment tools or ESET POS me Se ln ri en Yee
2. Diagnostic Occupational Therapy Evaluation of daily living skills,
© including self-feeding, dressing - and toileting. Informal assessment
tools may be used
3. Diagnostic Occupational Therapy Evaluation of Sensory Integration
4. Occupational Therapy Prosthetic Evaluation, when appropriate
5. Occupational Therapy Orthotic (Splint) Evaluation, when appropriate
6 . Assessment of need for positioning/seating equipment and other adaptive
equipment
7. Standard tests used must be from those listed below:
a. Pediatric Screening: A Tool for Occupational and Physical
Therapists rid Hs : : i
b. Joint Range of Motion Test
Ce Berry Developmental Test of Visual-Motor Integration (VMI)
d. The Meeting Street School Screening Test (MSSST)
e. The Macquarrie Test for Mechanical Ability
f. Early Intervention Developmental Profile (EIDP)
g. Preschool Development Profile (PDP) i
‘ Motor Free Visual Perception Test
i. Denver Developmental Screening Test
. Manual Muscle Tests Vad 3 Fela ;
K. Southern California Sensory Integration Test (SCSIT)
}. The Miller Assessment for Preschoolers (MAP)
m. The Developmental Test of Visual Perception (Frostig)
n. Test of Visual Perceptual Skills (TVPS) o +
QO. Bruininks-Oseretsky Test of Motor Proficiency :
P. Informal Methods, including observation of behavior during testing
and supplemental observations FIT ate Rand
Procedure
Code Fee Description
X0411 51.00 Occupational Therapy (OT) Evaluation
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Speech/Language Evaluation - includes jtems or tests used in identifying
communication impairments which adversely affect the functioning of the child.
These services must be provided by an individual licensed in Louisiana to
provide speech or language therapy services. This includes licensed speech
pathologists and certified speech/hearing/language specialists. These
services must include the following:
1. Oral Motor Examination/Consultation
2. Velopharyngeal Examination/Consultation
3. Child Language Consultation ~~.
4. Observations of Feeding Dysphagia, when appropriate ;
Procedure
Code fee Description
X0412 ~~ 45.00 Speech/Language Evaluation
Hearing Evaluation - includes tests, tasks and interviews used to identify
hearing loss in children whose auditory sensitivity and acuity is so deficient
as to interfere with normal functioning. These also include the
determination of range of hearing and nature and degree of hearing loss.
These services must be provided by an individual licensed in Louisiana to
provide audiology services, including licensed audiologists and physicans with
specialized training or experience in the diagnosis and treatment of hearing .
impairments and/or licensed audiologists. The tests used must be from those
listed below. These tests are billed separately.
Procedure
Code Fee Description
92552 $ 12.00 1. Puretone Audiometry (threshold); air only
92553 $ 13.00 2. Puretone Audiometry (threshold); air and
bone :
92555 $ 8.00 + 3. Speech Audiometry; threshold only
92556 $ 16.00 4. Speech Audiometry; threshold and
discrimination ;
92557 $ 29.00 5. Basic Comprehensive Audiometry (pure tone,
air and bone, and speech, threshold and
discrimination) (This test includes both
92553 and 92556)
92561 $ 20.00 6. Beskey Audiometry; diagnostic
92562 $ 8.00 7. Loudness Balance Test, alternate binaural
or monaural - ~~ -. "CC
92563 $ 8.00 8. Tone Decay Test Be
92564 $ 8.00 9. Short Increment Sensitivity Index (SISI)
92565 $ 10.00 10. Stenger Test, Puretone :
92566 $ 25.00 11. Impedance Testing (This test includes both
92567 and 92568) : :
92569 $ 9.00 14. Acoustic Reflex Decay Test
92571 $ 14.00 15. Filtered Speech Test
92572 $ 12.00 16. Staggered Spondaic Word Test
92573 $ 8.00 17. Lombard Test 5
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Louisiana Medical Assistance roar
EPSDT Services Provider Manual aw xan
Procedure
Code =: fee Description
92574 $ 8.00 18. Swinging Story Test
92575 $ 12.00 "19. Sensorineural Acuity Level Test
92576 $ 12.00 20. Synthetic Sentence Identification Test
92577 $ 10.00 21. Stenger Test, speech
92578 $ 18.00 22. Delayed Auditory Feedback Test
92581 $150.00 23. Evoked Response (EEG) Audiometry
92582 $ 16.00 . .. 24. Conditioning Play Audiometry
92583 $13.00 25. Select Picture Audiometry
92584 $ 85.00 26. Electrocochlegraphy
92585 $ 88.00 27. Brainstem Evoked Response Recording
Psychological Evaluation - includes a battery of tests, interviews and
behavioral evaluations that appraise ~ cognitive,’ emotional ~ and social
functioning and self-concept. . These must also include interpretations of
information about -child's behavior ‘and conditions relating to functioning.
These services must be provided by a licensed physician or psychiatrist,
licensed psychologist or certified school psychologist. Tests used must be
from those listed below and may also include informal measures, e.g., parental
observations and observations by others.
Procedure
Code Fee Description
X0413 $ 85.00 Psychological Evaluation
1. Adaptive Behavior Inventory for Children
2. AAMD Adaptive Behavior Scale :
3. Alpern-Boll Developmental Profile
4. Battelle Developmental Inventory
5. Bayley Scales of Infant Development
6. Behavior Rating Inventory for Autistic and Other Atypical Children
_ 7. Bender Visual Motor Gestalt Test
8. Brigance Kindergarten Screening .
9. Burks Behavior Rating Scales :
10. Catell Infant Intelligence Scale
11. Children's Apperception Test -.-.
12. Cognitive Observation Guide . .
13. Columbia Mental Maturity Scale =
14. Developmental Test of Visual Motor Integration
15. Frosty Developmental Test of Visual Motor Integration
16. Functional Profile F377] apm
17. - Gilmore Oral Reading Test rer un
18. Hiskey-Nebraska Test of Learning Aptitude
19. Inventory of Readiness Skills .
20. Kaufman Assessment Battery for Children
21. Key Math Diagnostic Arithmetic Test
22. Largo and Howard Play Assessment
23. Leiter International Performance Scale
24. McCarthy Scales of Children's Abilities
25. Merrill Palmer Scale of Mental Abilities
26. Motor-Free Visual Perception test
W é
: Ln SIN
a
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27. Nonverbal Test of Cognitive Skills
28. Peabody Individual Achievement Test
2g, Peabody Picture Vocabulary Test - Revised
30." Projective Drawings =: en
31. Psycho-Diagnostic Tests
32. Rorschach Projective Technique
33. Ravens Progressive Matrices
34. Sentence Completion Test
35. Southern California Ordinal Scales of Development
36. Stanford-Binet Intelligence Scale TTA
37. System of Multicultural Pluralistic Assessment
38. Test of Nonverbal Intelligence -
39. Test of Visual Perceptual Skills
40. Thematic Apperception Test (TAT) ~~
41. Ugziris-Hunt Ordinal Scales of .Infant Development
42. -Wechsler Adult Intelligence Scale - Revised
43. ‘Wechsler Intelligence Scale for Children - Revised (WISC-R)
44. Wechsler Preschool and Primary Scale of Intelligence
45. Westby Play Scale ah
46. Wide Range Achievement Test -
47. Woodcock Reading Mastery Tests
2.4.4.3.2 Treatment Services
Physical Therapy Treatment includes services directed toward the prevention or
minimization of disability, relieving pain; developing, improving, or
restoring motor function; controlling postural deviations; and through the use
of therapeutic exercises and rehabilitative procedures, maintaining maximal
performance within a child's capabilities. These services must be provided by
a physical therapist licensed in Louisisana.
Procedure
Code fee - Description
97110 16.00 - 1. Physical medicine treatment to one area
: a initial 30 minutes; therapeutic exercise
97112 16.00 2. Physical medicine treatment to one area
initial 30 minutes; neuromuscular re-
~~ +. education .. Hoy Sim
97114 16.00 3. © Physical medicine treatment to ‘one area
initial 30 minutes; functional activities
97116 16.00 4. Physical medicine treatment to’ one area
initial 30 minutes; gait training
97118 16.00 5. Physical medicine treatment -to “one area
initial .30 minutes; electrical stimulation
(manual) @ =... oo Eider
97124 10.00 6. Physical medicine treatment to one area
initial 30 minutes; massage
97145 8.00 y J Physical medicine treatment to one area,
each additional 15 minutes; limit -2 per
day
Y7200 16.00 8. Combination of physical medicine treatment
procedures, initial 30 minutes
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Occupational Therapy or Treatment means improving, developing, or restoring
functions impaired or lost through illness, injury, or deprivation. .Improving
ability to perform tasks for -independent functioning ‘when functions are
impaired or lost. Preventing, through early intervention, initial or further
impairment or loss of function, These services must be provided by an
occupational therapist licensed in Louisiana. Feith iE AL
Procedure : ; FTES ne ra
Code fee - TH. Description 31 Cs SARE a RC eT Tal
97500 16.00 1.“ Orthotics training (dynamic bracing : iz
; splinting), upper extremities; initial 30
minutes; i ~ Br TL a Sd nh
97501 8.00 2. Orthotics training, seach . additional 15
pire “- minutes; limit - 2 per day Teepe
97530 16.00 ~.3, Kinetic:: :.activities :/ to increase
a zo + + “i'coordination, strength .and/or . range of
motion, one area (any two extremities or
trunk); initial 30 minutes oo
97531 8.00 4. Kinetic activities as above; additional 15
minutes each visit; limit - 2 per day ;
97540 16.00 §. Training in activities of daily living
(self care skills and/or daily life
: management skills); initial 30 minutes
97541 "8.00 6. Training in activities of daily living as
above; additional 15 minutes; limit - 2 per
: day. <= i
97720 i>. 1616.00 7. Extremity testing for strength, dexterity,
LR Aho or stamina; initial 30 minutes
97721 8.00 8. Extremity testing as above; additional 15
minutes
Speech/Language or Hearing Therapy or Treatment is a service delivery
‘pattern. in _ which services are provided to a child with a diagnosed
speech, language or “hearing ‘disorder by a licensed speech pathologist or
certified speech/hearing/language specialist. This must include the following
intervention services, as appropriate; . : Ea
1. Speech/language or hearing therapy (individual)
2. Stuttering therapy ~~. -
3. Speech reading/oral rehabilitation
4. “VYolce therapy "7 Tlioxwesdl lies,
5. Feeding/dysphagia °~~ ~*~ * “~~
6. .- Dysphagia_training *' ~~
7." Esophageal speech training therapy
8. Speech defect training therapy
2-38
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual
Procedure
Code Fee Description
X0423 15.00 Speech/Language or Hearing Therapy (Individual);
% - 30 minutes ~- . -- ; :
Y2611 10.00 Speech/Language or Hearing Therapy (Individual);
20 minutes
X0424 8.00 ; Speech/Language Therapy; additional 15 minutes;
limit - 2 per day ay
Y2509 8.00 Speech/Language or Hearing Therapy (Group); 30
: - MIiNULES -. icc oo ; EY : 3
Y2510 5.00 Speech/Language or Hearing Therapy (Group); 20
: i minutes ~~. vi. , iba
Y2511 : 4.00 Speech/Language or Hearing Therapy (Group);
additional 15 minutes; limit - 2 per day
Psychological Therapy/Treatment . means planning, managing, and providing a
program of psychological services including psychological counseling for
children with diagnosed psychological problems and their families. These
services must be provided by a licensed physician or psychiatrist, licensed
psychologist or certified school psychologist. This must include one or more
of the following modalities:
Procedure
Code foe + Description
X0420 50.00 1. Individual counseling/therapy, 60 minutes
X0425 25.00 : 8 Individual counseling/therapy, 30 minutes
X0421 25.00 3. Group counseling/therapy, 60 minutes
X0422 ~ 25.00 4. Family counseling/therapy, 60 mintues
2.4.5 - DOCUMENTATION REQUIREMENTS
Providers must make all records of EPSDT services provided to children with
special health needs available to the Bureau for monitoring and auditing
purposes. These providers must maintain the following documentation for at
least three years from the date of service on all children for whom claims
have been submitted. SEAN VR :
a. Dates and results of all evaluation/diagnosis provided in the interest of
establishing or modifying an IEP or IFSP, including specific tests
performed and copies of evaluation and diagnostic assessment reports;
b. Copies of the IEP or IFSP documenting the need for the specific therapy
or treatment services;
c. Documentation of the provision of treatment service by individual
therapists and individuals providing treatment including billing forms,
10g books, reports on services provided and the child's progress, and the
child's record(s);
d. Documentation of dates and results of the most recent medical, vision
and/or hearing screening(s);
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EPSDT Services Provider Manual
2.5 INTERAGENCY COORDINATION
Interagency collaboration activities and interagency coordination address
several goals simultaneously.
teem
a. Containing costs and improving services by reducing service overlaps or
duplications and fragmentation;
:
b. Focusing services on targeted groups of eligibles or geographic areas in
need of special attention; Bt : {ai
C. Defining the scope of the programs in relation to each other;
The Bureau is required to coordinate EPSDT services and enter into agreements
with Title V (Maternal and Child Health Program) grantee (e.g., the Office of
Public Health), and other state agencies responsible for administering health
services and vocational rehabilitation services. Coordination includes joint
cooperative efforts and formal linkages with related. public and private
programs involved in outreach, screening, diagnostic or treatment services,
health education, counseling, case management, facilities, funding and other
assistance aimed at achieving a comprehensive, effective system of health care
for low income children and their families.
2.5.1. Related Agencies and Programs
These related agencies and programs include but are not limited to:
a. Office of Public Health
(1) Title V (Maternal and Child Health Program)
(2) Title X (Family Planning)
(3) id Food Program for Women, Infants and Children
WIC
b. Department of Social Services, Office of Community Services
(1) Title XX (Social Services Programs) i Fn poe
(2) Title IV-E (Foster Care) :
c. State and Local Education Agencies SA 3 Ee
(1) Department of Education, Office of Special Education Services
. - (2) Child Search .
(3) Head Start Agencies
2-40
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EPSDT Services Provider Manual
HEALTH EDUCATION/ANTICIPATORY GUIDANCE GUIDELINES
Birth
First complete examination, usually completed within the 1st 24 hours of life,
preferably within the first 6-12 hours.
Common findings
Explain findings which may be present or be expected to develop during this
age period such as:
= 2
Umbilical cord Stump separation and care
Penis - Circumcision and cleaning
Vagina - Discharge % :
Skin and hair - Coloration (jaundice, mottling, peripheral cyanosis)
Rashes, "birth marks," loss of hair
Nervous system - Moro reflex, chin quiver
Head - Molding, cephalohematoma
Breasts - Swelling, discharge
Eyes - Color change
Procedures
Explain any procedures which may be done during this time period such as:
Metabolic screening
Circumcision
Blood glucose testing
Nutrition and feeding
.- Breast/formula feeding
- Timing and amount of feedings
i’ Preparation of formula
- Supplements
- Spitting up
- Weight loss
- Stool types & changes
" WIC Program
Hygiene
- Bathing
- Diapering
- Umbilicalcord care
- Skin, hair/scalp care
- Appropriate clothing and bedding
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Parenting practices
Discuss areas of concern common to this age such as:
- Bonding
= Holding and handling
- Showing affection
- Sibling reactions
- when to consult a physician
- postpartal adjustments and depression
Development and behavior |
- Crying
Pacifier use
Sleep patterns
» Individuality
Injury prevention
- Car safety seats-purchase (or rental) and use
Household water temperature
- Crib safety
; Danger of leaving an infant unattended, alone or with young child or pet
Individual concerns and problems
; Examination/assessment findings
- Specific family concerns
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By One Month
Injury prevention*
- Car safety seat use
- Danger of leaving infant unattended
- Home environment hazards
-- Smoke detectors
-- Dangers associated with toys, necklaces, cords
-- Burn prevention
Hygiene*
- Bathing
- Diapering
- Appropriate clothing and bedding
- Skin care ;
Nutrition/feeding
Breast/formula feeding
-- Timing
-- Amounts
-- Preparation
Supplements
Spitting up
WIC Program
Parenting practices
Holding and handling
Stimulation and parent/infant interaction
How to deal with illnesses, accidents
Choosing care providers
Development and behavior
Individuality
Sleep
Bowel and bladder
Crying
Self comforting behaviors
Individual concerns and problems
Examination/assessment findings
Specific family concerns
Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if reinforcement is needed.
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual -
Two Months
Injury prevention*
- Car safety seat use
“ Danger of leaving infant unattended
- Home and environment hazards
-- Playpen use
-- Appropriate toys
Hygiene*
Immunizations®*
- Fever control
Nutrition/feeding*
- Supplements
- Solid foods - delaying introduction
Parenting practices*
- Family relations
- Interaction with infant
- Discipline
Development and behavior*
> As age and child specific
Individual concerns and problems
- Examination/assessment findings
“= Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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Four Months
Injury prevention*
- Ingestion of harmful objects or substances (PICA)
- Mobility dangers
- Mouthing, dangers of small objects
Hygiene*
- Teething
Nutrition/feeding*
Immunizations*
Parenting practices*
i’ Demonstrating affection
- Discipline
Development and behavior*
- Milestones and developmental variability
- Social behavior
- Sleep patterns
- Safe toys
- Self comforting behaviors
-- Thumbsucking
Individual concerns and problems
= Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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Six Months
Injury Prevention*
- Mouthing, dangers of pica and small objects
- Childproofing environment :
- Use of gates
- Dangers of plastic bags
Hygiene*
Immunizations*
Nutrition/feeding*
- Nursing bottle caries and possible otitis media
- Solid foods
Parenting practices*
= Speech stimulation
- Parent/child games
Development and behavior*
= Teething
- Stranger awareness
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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Nine Months
Injury prevention*
- Change to toddler safety seats when infant weighs 20 1bs.
- Water safety
= Mobility dangers
- Burn safety
- Poison-proofing home
Hygiene*
- Shoes
- Nursing bottle mouth
Immunizations
Nutrition/feeding*
- Weaning
- Appetite
- Finger foods
Parenting practices*
- Discipline
Development and behavior
- Cognitive growth
- Discipline, use of “No“
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
» Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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EPSOT Services Provider Manual "uc 0
ri
12 Months
Injury prevention*
- Toddler safety seats
- Water safety
- Burn safety
- Poison-proofing home
- Protection from falls
Nutrition/feeding*
" Weaning
- Finger foods
Parenting practices*
- Encouraging speech development
Development and behavior
- Independent behaviors
- Language development
- Interaction with parents and siblings vs. playing alone
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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15 Months
Injury prevention
- Change to toddler car safety seat should have been done
- Safety cap use
- prevention of falls
- Electrical injuries
- Plastic bags and balloons
Hygiene*
- Toilet training (readiness signs)
Immunizations™®
Nutrition/feeding*
- Weaning
- Self-feeding
- Weight gain and growth
- Snacks
Parenting practices*
- TV viewing :
- Positive reinforcement of good behavior
- Day care
Development and behavior*
- Imitative behavior
- Play/exploration
- Negative behavior
- Self comforting behaviors
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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EPSDT Services Provider Manual
18 Months
Injury prevention*
- Stair and window safety
“ Play supervision
Hygiene*
- Toilet training
; Tooth brushing
Immunizations*
Nutrition/feeding*
- Snacks
- Family meals
- Food likes/dislikes
Parenting practices*
- Discipline
- Day care
- TV
Development and behavior
- Sleep practices
- Exploring behavior
- Sharing
- Self care and self expression
. Self comforting behaviors
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
» Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed. :
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EPSDT Services Provider Manual
Two Years
Injury prevention*
- Play supervision
- Age appropriate toys
Hygiene*
- Toilet training
= Tooth brushing
Nutrition/feeding*
- Supplements
. Feeding problems
Parenting practices*
- Parent/child interaction
-- Reading to child
-- Talking to child
-- Toys
- TV limits
- Day care
- Siblings
Development and behavior*
- Sleep
-- Naps
-- Discuss change from crib to regular bed
- Curiosity
= Speech development
» Structured toys
- Physical activity
- Verbal and listening skills
- Use of books :
- Peer contact
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
x Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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EPSDT Services Provider Manual
:
Three Years
Injury prevention*
- Car seat belt use
- knife and firearm storage
- Play and safety supervision and activities
- Strangers
Hygiene*
Nutrition/feeding*
- Balanced diet/junk food
- Self feeding
- Supplements
Parenting practices*
- Consistency in parental approach
- Of fering choices
’ Out of home experiences
- Discipline techniques
; Nursery school
Development and behavior*
- Self discipline
- Cooperative play
- Questioning behavior
- Sexual identification
Individual concerns and problems
= Examination/assessment findings
- Specific family concerns
= % Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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EPSDT Services Provider Manual
Four Years
Injury prevention*
- Car seat belt use
- Play supervision
- Safe toys
- Bike riding
- Home safety rules
- Teach name, address, telephone number
Hygiene*
- Need for privacy
- Toilet training
Immunizations
Nutrition/feeding*
- Portion size
- Family meals
Parenting practices*
- Sex education questions
- Peer interactions
- Sleep
- Chores and responsibilities
- Appropriate play
- Exploratory trips
- TV
- parental limits vs. independence
Development and behavior*
- Communication skills
Congnitive skills
- Peer and parent relationships
= Separation
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these topics was
inappropriate at an earlier age or if needed.
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Bus
EPSDT Services Provider Manual
Five Years
Injury prevention*
- Bike safety
- Fire safety
- Memorize name, address, and telephone number
Hygiene*
- Self care
-- Toilet :
-- Dental
. An a
-- Dressing
Nutrition/feeding*
- Eating habits
- Snacks
- Meal time atmosphere
Parenting practices*
= Testing by child
- Chores and responsibilities
- Sex education
= Discipline
Normal development/behavior*
- Discipline
- Chores
- Peer interaction
- School readiness
- Following directions and rules
- Fantasy play
- Physical skills
Individual concerns and problems
- Examination/assessment findings
- Specific family concerns
* Refer back to earlier topics, if coverage of these fopics was
inappropriate at an earlier age or if needed. :
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EPSDT Services Provider Manual
Six Years
with child
Health Habits and Self Care
Diet and weight
Physical activity
Dental hygiene
Bike and skate safety
Sleep
TV
water and vehicle safety
Communication with parents and peers ,
parents
Good Parenting Practices
-- Home rules and limits
-- Spending time with child
-- Supervision
-- Allowance
-- Encouraging self esteem
-- Encourage out of home activities, hobbies, physical activity
-- Safety
Revised October 9, 1990
Louisiana Medical Assistance Program
+
EPSDT Services Provider Manual 3
Eight Years
With child
- Health Habits and Self Care
-- Diet and weight
-- Physical activity
-- Dental hygiene
-- Bike and skateboard safety
-- Sleep
-- Seat belt use
-- Communication with parents
-- Siblings
-- Peer activities
With parents
- Good Parenting Practices
-- Establishing rules
-- Communication
-- Supervision
-- Allowance
-- Parental role model
-- Age appropriate independence
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EPSDT Services Provider Manual antler i
Ten Years
With child
- Health Habits and Self Care
-- Diet and weight
-- Physical activity
-- Dental hygiene
-- Bike, skateboard and trampoline safety
-- Drug, alcohol, and tobacco use
-- Sleep
-- Sex education at home and at school
-- Seat belt use a
-- TV and video games
-- Social interaction
-- Educational activities
With parents
- Good Parenting Practices
-- Rules and expectations
-- Communication and time with child
-- Supervision
-- Allowance
-- Affection
-- Safety concerns
-- Power tools
-- Water
-- All terrain vehicles
-- Firearms
-- Sex education
-- TV
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y :
EPSDT Services. Provider Manual ie
Twelve Years
With adolescent
- Health Habits and Self Care
-- Diet and appropriate weight
-- Physical activities
-- Dental hygiene
-- Sleep
-- Risk taking behavior
:
-- Drug, alcohol and tobacco use gr Trade E RP RL
-- Physical growth and maturation
a
- Acne : ih
- Menstruation
_ Breast or testes self examination : :
- Sex education, as appropriate to age, development, activity and family
situation . ae) Le :
- Social interaction
-- Communication with family and peers
-- Extra curricular activities
-- Job
- Academic activity
With parents
- Good Parenting Activities
-- Establishing activities
-- Spending time with adolescent
-- Supervision
-- Communications
-- Role model
-- Sex education
-- Promote independence
-- Decision making
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EPSDT Services Provider Manual
14 Years
With adolescent
- Health Habits and Self Care
-- Diet and appropriate weight
-- Physical activity and athletics
-- Dental hygiene
-- Bike and vehicle safety
-- Drug, alcohol and tobacco use
-- Sleep :
-- Personal safety practices
- Sex Education, as appropriate to individual and family concerns
= Social Interaction
:
-- Communication with family and peers
-- Extracurricular activities
-- Job
-- TV
- Educational Activities
With parents
- Good Parenting Practices
-- Establishing rules
-- Spending time with adolescent
-- Communication
-- Supervision
-- Privacy
-- Allowance
-- Role model
-- Independence
-- Showing affection
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Louisiana Medical Assistance Program
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EPSDT Services Provider Manual
16 Years
With adolescent
- Health Habits and Self Care
-- Diet and appropriate weight
-- Physical activity
-- Dental hygiene
-- Drug, alcohol and tobacco use
-- Sleep
-- Personal safety
-- Vehicle safety
:
- Sex Education, as appropriate to individual and family concerns
Social Interaction
-- Communication with family and peers
-- Extracurricular activities
-- Job
- Educational activities
With parents
- Good Parenting Practices
-- Establishing rules
-- Spending time with adolescent
-- Communication
-- Supervision
-- Allowance
-- Privacy
-- Showing affection
-- Role model
-- Independence
-- Decision making
-- TV
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EPSDT Services Provider Manual
18 Years
With adolescent
- Health Habits and Self Care
-- Diet and appropriate weight
-- Physical activity
-- Dental hygiene
-- Drug, alcohol and tobacco use
-- Sleep
-- Pap smear
-- Personal safety
-- Vehicle safety
-- Risk-taking behavior
- Sex Education, as appropri
- Social Interaction
-- Communication with family and peers
-- Home separation
-- Extracurricular activities
-- Job
- Academic Activities
- Plans for Future
ate to adolescent and family concerns
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EPSDT Services Provider Manual .
20 Years
- Health Habits and Self Care
-- Diet and appropriate weight
-- Physical activities
-- Dental hygiene
-- Drug, alcohol and tobacco use
-- Sleep
-- Breast and testes self examination
-- Personal safety ia
-- Vehicle safety
-- Risk-taking behavior
- Sex Education, as appropriate to individual
- Social Interaction
-- Communications with family and peers
-- Extracurricular activities
-- Job
Educational Activities
Plans for Future
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EPSDT Services Provider Manual
3. CLAIMS BILLING AND REIMBURSEMENT
3.1. CLAIM BILLING INSTRUCTIONS
This section will lead the provider step by step through the process of
billing MAP for EPSDT claims.
: hot
Effective October 1, 1990, all EPSOT providers will be required to bill
Medicaid by Electronic Media Claims (EMC) submission. Claims must be received
by Unisys within 60 days of the date of service in order to be processed and
the provider reimbursed. wh : | e Bal Las tar
.EMC is the submission of claims via computer. Claims can be sent for
processing on a diskette (3-1/2" x 5-1/4", or 8"), on tape (reel-to-reel), or
by telecommunications (modem). EMC runs on any [BM-compatible PC and billing
agencies are available. ds 2 a vy
Claims requiring prior authorization or claims having attachments cannot be
billed via EMC. When it is necessary to submit a form, refer to Section 3.3.
For more information or to request EMC specifications, please contact the EMC
Coordinator.
Unisys/Louisiana Medicaid
8591 United Plaza Blvd.
Suite 100
Baton Rouge, LA 70809
ATTN: EMC Coordinator
(504) 924-7051
3-1
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Louisiana Medical Assistance Program
EPSDT Services Provider Manual
3.1.) EPSOT Medical Screening Services Billing Form 107 Instructions
The following EPSOT medical screening billing instructions must be carefully
followed to format the required electronic media accurately. ‘An asterisk (*)
by an item indicates the information which must be correctly completed by the
provider before the claim will be processed for payment by Unisys. Item by
item instructions follow. Refer to Figure 3-1, Form 107, at the end of these
instructions. 5 : :
- 8 %
PA
ar 3
:
-
1.* - provider Number - Enter the seven digit Provider I.D. Number which ‘was
assigned by Medicaid. In the case of a Group Practice, enter ‘the “group
number. : LV RRS SEE FO EE FE
~~
2.* Medical Assistance Identification Number - Enter the patient's 13 digit
~~. Medical Assistance 1.D. Number exactly as it appears on the patient's
monthly medical card. When multiple persons’are listed on one I.D. card,
make certain that the last two digits of the I.D. number are the correct
individual suffix for the patient. If this item is blank, the claim will
be returned to the provider. is :
3.* Patient's Last Name, First Name, MI - Enter the patient's name last name
first, first name and middle initial. Spell the name exactly as it
appears on the patient's Medical I.D. Card.
4.* Attending Provider Name - Enter the name of the agency or the group
practice doing the screening, i.e., OPH, School Board, New Orleans Health
Department or group .practice name.
5.* Attending Provider Number - Enter the seven digit Provider I.D. Number
assigned by the Louisiana Medical Assistance Program. In most instances,
this item will be the same as Item 1. In cases where a physician does
the screening for the agency or a group practicing member, the
physician's provider number should be entered.
6. Date of Request - Leave this item blank.
7. Patient's Address - Enter the patient's permanent address.
8. Sex - Leave this space blank.
9. Race - Leave this space blank.
10. Height - Leave this space blank.
11. Weight - Leave this space blank.
12. Head Circumference - Leave this space blank.
13. HCT - Hematocrit - Leave this space blank.
14. HGM - Hemoglobin - Leave this space blank.
15. Birth Weight - Leave this space blank.
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
16.* Birth Date - Enter the patient's date of birth exactly as it appears on
the Medical Assistance 1.0. Card using six digits (MM DD YY). If a field
has only one digit, enter a leading zero. Caliah :
17. BP - Blood Pressure - Leave this space blank.
18. Medical Screening Information
A.* Medical Screening Codes - Enter the appropriate code in the box
provided relating to whether the screening was -performed by a
nurse, physician or physician's assistant.
[ - Medical Screening (Nurse) = = es The Cl ;
S - Medical Screening (Physician or Physician Assistant)
«
B. Medical Screening Complete - Leave this space blank.
C.* Date of Current Medical Screening - Enter the date of the screening
Using six digits (MM DD YY). If a field has only one digit, enter a
leading zero.
D.* Total Charge - Enter the amount billed to Medicaid for the screening
services rendered to the patient.
E. Date of Last Medical Screening - Leave this space blank.
F. Medical Record Number - If a patient's account (Medical Record)
number 1s entered, it will appear on the Remittance Advice. It may
consist of letters and/or numbers and may be a maximum of 13
digits.
19. Screening Results
; A.* Referral Data - Check the appropriate blocks to indicate whether a
patient was referred for diagnosis, treatment or other services as a
result of the medical, vision, hearing or dental screening. More
than one block may be checked. Correct completion of this item is
essential for follow-up and tracking purposes and to comply with
federal regulations. Medicaid is mandated to cover only those EPSDT
diagnosis, treatment and other ‘services found to be medically
necessary as a result of condition(s) found during the medical
vision, hearing or dental screening. If “c" or “d" is checked,
suspected conditions must also be checked in Item 19C. Referred In-
_ House (c) includes self-referrals. -A referral must be checked in
(c) or (d) in order to bill for nurse, social worker or nutritionist
counseling , consultation or follow-up or nurse intervention on the .
screening date. A referral must also be checked if a physician
office visit is billed on the screening date for diagnosis or
treatment.
a. No Referable Condition
b. Not Referred
Co Referred In-House
d. Referred to Private Provider
3-3
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EPSDT Services Provider Manual
oi
»
B.* Immunizations - Leave this space blank.
c.* Suspected Conditions - “Suspected Condition" is defined as a past or
newly found condition that needs further diagnosis, possible treatment or
follow-up. Do not check a condition if no referral (self or other
provider) is being made as a result of this screening. Do not check Y or
7. Check no more than six conditions that the patient is suspected to
have or which a referral was made as a result of this medical,-vision,
hearing or. dental -screening. - This includes self referrals in which the
screening provider performs the diagnosis, treatment and/or other follow-
up services. The following are to be used as guidelines to complete this
section and do not .include every possible condition. This item must be
completed if "c" or "d" is checked ip -item 19C. This item must be
completed in ‘order to bill for a nurse, social worker or nutritionist
consultation, counseling or follow-up, nurse intervention or diagnosis
and/or treatment by a physician on.the screening date.
A. VISION
1. Refractive Error
2. Strabismus
3. Cataracts
4, Glaucoma
5. Enucleation
6. Conjunctivitis
7. Any tye Injury
8. Any Eye Infection
9. Tumors
10. Ptosis
11. Color blindness
12. Abnormal pupillary reflexes
13. Other suspected vision related problems
B. HEARING
1. Otitis Media or Externa %
2. Conductive or Sensorineural Hearing Loss
3.- Foreign Body = - fo : ;
4. Chronic or Recurrent Ear Infection
5. Mastoiditis IE i of
6. Punctured Ear Drum .:
7. Tubes in Ears : Sette TREN nn amg,
8. Other Suspected Hearing Related Problems . .
C. DENTAL
1. ‘Caries
2. Gum Disease
3. Malocclusion
4. Missing or Broken Teeth
5. Thrush
6. Other Suspected Conditions Affecting Teeth or Gums
3-4
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EPSDT Services Provider Manual
SICKLE CELL ANEMIA
(As documented by Lab Report)
LEAD POISONING
(As Lab Report is received)
NUTRITIONAL
Iron Deficiency Anemia
Low Weight for Height
High Weight for Height Lona,
Unusual Height (Low or High)
Food Allergy
Inadequate or Inappropriate Diet
"Vitamin Deficiency RAL ,
Cholesterol Elevation g
Other Suspected Nutrition/Diet Related Problems
O
o
O
o
O
~
N
O
G
L
W
N
»
RA
“®
LJ
GENITOURINARY SYSTEM
Phimosis
Incontinence
Enuresis
Undescended Testicles
Venereal Disease
Menstrual Cramps or Other Gynecologic Problem
7. Infection of Bladder or Kidney
8. Albumin in Urine
g. Blood in Urine
10. Glucose in Urine
11. Other Suspected Genitourinary System Related Condition
DISEASES OF THE CIRCULATORY SYSTEM
Blueness Around Mouth (Cyanosis)
Irregular Pulse
Heart Disease
Rheumatic Fever
Heart Murmur ifn mee
Other Suspected Circulatory System Related Condition
HYPERTENSION ~“%-
(According to American Academy of Pediatrics Guidelines)
SKIN, SUBCUTANEOUS TISSUE, HAIR
Impetigo
Dermatitis
Acne
Insect Bites
Abscesses
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual ir
6. Cysts
7. Fungus
8. Scales
9. Loss of Hair
10. Eczema
11. Hives
12. Boils
13. Abrasions
14. Scabies
15. Keloids
16. Burns Th
17. Other Lesions or Lacerations .. =
18. Other Suspected Skin Related Condition
MENTAL DISORDERS
(Confirmed by Psychiatric Diagnosis and/or Psychological Evaluation)
BLOOD AND BLOOD-FORMING ORGANS
Hemophilia
Leukemia
Thalassemia
Anemia (Not Iron Deficiency)
Other Suspected Blood and Blood-Forming Organ Related
Conditions
CONGENITAL ABNORMALITIES
1. Spina Bifida
2. Cleft Palate or Cleft Lip
3. Other Suspected Congenital Abnormalities
NERVOUS SYSTEM
1. Guillain Barre Syndrome
2. Epilepsy
3. Convulsions
4. Tremors
5. Microcephaly
6. Macrocephaly
'7.-: Cerebral Palsy .: :
8. Multiple Sclerosis
9. Other suspected Nervous System Related Conditions:
SICKLE CELL® TRAIT :°:
Pp. INFECTIVE AND PARASITIC
1. Lice
2. Pin Worms
3. Round Worms
4. Communicable Diseases
5. Hepatitis
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
6. Mononucleosis
7. Meningitis =
8. Tuberculosis (Or Recent Converter on Medication)
9. Other Suspected Infective and Parasitic Related Conditions
Q. PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM
R. ACCIDENTS, POISONING, AND VIOLENCE
1. Child Abuse
2. Substance Abuse
3. Sexual Abuse
4. Frequent Accidents
S. SYMPTOMS OF ILL-DEFINED CONDITIONS
Fever
Malaise
Insomnia
Headaches
Nosebleeds
Hyperventilation
Fainting
Edema
Heartburn
Weight Loss ;
Other Symptoms of I11-Defined Conditions
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T. DEVELOPMENTAL DELAYS
1. Failed PDQ, DOST or Other Developmental Testing
2. By Observation or History
: 3. Physical, Social and/or Emotional Developmental Delay
” 4. Mental Retardation :
U. * MUSCULOSKELETAL AND CONNECTIVE TISSUE SYSTEM :
1. Hernia
2. Scoliosis or Kyphosis
3. Muscular Dystrophy
4, Bow Legs
5. Toeing In or Out
6. Breast Masses
7. Lymph Gland Enlargement
8. Other Suspected Musculoskeletal Or Connective Tissue Conditions
V. RESPIRATORY SYSTEM
1. Tonsilitis
2. Sore Throat
3. Asthma
4. Hay Fever
5. Cough
6. Respiratory Allergy
3-7
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual alt
7. Upper Respiratory Infection
8. Other Suspected Respiratory Related Conditions
Ww. DIGESTIVE SYSTEM
Nausea
Vomiting
Diarrhea Fo x
Ulcers
Pyloric Stenosis
Constipation
Diverticulosis
Hemorrhoids $d Th
Other Suspected Digestive Related Conditions
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X. ENDOCRINE AND METABOLIC DISEASE
1. Hypothyroid
2. Hyperthyroid
3. Diabetes
4. PKU
5. Hypoglycemia
6. Enzyme Deficient Disorder
7. Other Suspected Endocrine or Metabolic Conditions
Y. MORE THAN SIX OF THE ABOVE (Self-Explanatory) DO NOT USE THIS SPACE
Z. OTHER DO NOT USE THIS SPACE
20. Signature, Title of Provider Representative, Parish, Date - Leave this
space blank. :
21.* Date - Signature of Provider - Upon completion of the medical screening,
. the provider must date and sign this form. - Signature stamps or computer
generated signatures are acceptable but must be initialed. If left blank
or if the stamped or computer generated signature is not initialed, the
claim will be returned to the provider.
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSOT Services Provider Manual
— — — — — —— E— TE— CE— —
— ——
He —
CE — —— —— ——— —— —— — ——— —— = — pale
RECIPENTS MAY BE SCREENED
ACCORDING TO THE FOLLOWING |
PERICOICITY SCHEDULE
(1) OURING THE 1ST MONTH OF LIPE
(2) 2-3 MONTHS OF UPE : -
(3) &7 MONTHS OF LPE
{4) SETWEEN 8-13 MONTHS OF AGE ;
(S) AT 2 3. AND $ YEARS OF AGE |
Q TOTAL OAR0E
rr — (6) AND EVERY 3 YEARS THEREAFTER
w SCREENING RESULTS i
|| A REFERRAL DATA © C SUSPECTED CONDITIONS (NO MORE THAN SIX (6) CAN 38 C-ECXED)
i Yona a CO van ; nC osass oF NE MEVOLS SYSTEM
; 0 ao no wrens coromon s Orwmn a 0 soos cu mar
; c CO coms ? CJ 0euCIVE Ar PARASIRC DEAS
Od § NOV PEND, OVER REASON a OC scasau mee Qa CJ COMUCARONS OF PREGNANCY. ORLOMITH,
nf hp |
¢ OO worcmoen
:
dd C MFEEED FOUR tO raramrei CHEASE AO 0 Acooeeas rPOBONING. AMO VIOUINCE
fRALID TO BENE ATURE OF NOU)
O 0 AEE 10 FRMJIE FROVDER a 7] nai OF 0 ORCHID! TE. 3 OO sees oF UOTE CHORDS
nC] coneams OF WE CROAAIOEY SIA t CO ovaomeay cass
i 5 iL ELATIONE t OO susan du CJ cmmasms GF 0 MACACEASM
; + 3 © cumesEl CF WE SIN 4O SAS tk
O COMPLETED AS OF SCHIDS0 i " 8 wv J ommasss OF NE EIFRAICRY VIFDA
; = : ¢ OO woe moms we [0] DRAM OF ME CORNING PET.
a COMAETED AT SCHEENG tC] sumeans OF ME MOOD 2@ BOS: : 1 12] 00086 100 VITHETHC DRAG
:
t OO wom nus $ Cr BE AOR
% SCORE a [2] COPS. MCI z Oonem
a: G4 ASRS WE ICFENS RIOERAY FOR Tl DARE SIOWN BROW AND TWAT WE CENT § OUR A SCHIRGWS ACCCRRI0 0 0
FESCERCHY nad # a VCE § EPORD On A ARGUS GUI. He CHT 45% Hal A! BUCA CAD FOR TAT STOR PERSE
sys - 17
Lee
Ser, ar 8 ,EUIV Pan
-
Figure 3-1. EPSDT Screening Services Billing Form 107
3-9
Revised October 9, 1990
Louisiana Nedicall Assistance Program...
EPSDT Services Provider Manual
3.1.2 HCFA Claim Form 1500 (1-84) Billing Instructions
These instructions must be carefully .followed to - format the required
electronic media accurately. Refer to Figure 3-2, HCFA Claim Form 1500,
located at the end of these instructions. = Items marked with an asterisk (*)
must be completed or the claim will be denied for payment.” Roa
Check the appropriate program block(s) at the top of the form.
a
ce Se 5 2
#1. patient's Name - Enter the name of the ‘patient - first name, middle
initial, last name. Spell “the name “exactly -as “it ‘appears ..on the
patient's -Medicaid -I.D. carde — oo —voommn 0 uz
En Si PN
*2. patient's Date of Birth - Enter the patient's date of birth as reflected
on the Medical 1.D..card using six digits (MM DD YY). If a field has
only one digit, enter a leading zero."- ay cn ng
3. Insured's Name - Leave this space blank.
4. patient's Address - Enter the patient's permanent address.
5. Patient's Sex - Check the appropriate box.
x6. Insured's I.D. No. (Medicare and/or Medicaid) - Enter the patient's .13.
digit Medical Assistance 1.D. Number exactly as on the patient's monthly
Medical I[.D. card for the current month. when multiple persons are
listed on one. I.D. card, make certain that the last two digits of the
1.0. number are the correct individual suffix for the family member who
is the patient. If the number does not match the patient's name in Items
1-3, the claim will be denied. If this item is blank, the claim will be
returned to the provider. :
7. Patient's Relationship to Insured - Leave this space blank.
8. Insured's Group Number - Leave this space blank.
9. Other Health Insurance Coverage - Enter the plan name(s) and the Medicaid
Third Party Liability (TPL) carrier code(s) number (if applicable).
10. Was Condition Related to: Leave this space blank.
11.-Insured's Address - Leave this space blank. .
12. Patient's or Authorized Person's Signature - Leave this space blank.
13. 1 Authorize Payment -"Leave this space blank.
14. Date of: - Leave this space blank.
15. Date First Consulted You for This Condition - Leave this space blank.
16. Has Patient Ever Had Same or Similar Symptom? Leave this space blank.
16 a. If Emergency Check Here - Leave this space blank.
3-10
Revised October 9, 1990
17.
18.
19.
20.
- 2.
22.
*23.
*24.
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
Date Patient Able to Return to Work - Leave this space blank.
Dates of Total Disability - Leave this space blank.
Name of Referring Physician or Other Source - Enter the physician's name.
‘If provider shown in Item 31 is an Tndependent laboratory, enter the
referring physician or agency.
For Services Related ‘to Hospitalization Give Hospitalization Dates -
Admitted (MM OD YY)/Discharged (MM OD YY). If there is only one digit in
a field precede that digit with a zero.
Name and Address of Facility Where Services Rendered (if other than home
or oyrice) = Leave this space blank.
Was Laboratory Work Performed Qutside Your Office? - Leave this space
blank.
.
A. Diagnosis or Nature of I11ness or Injury - All claims must contain a
medical ly accepted description of the diagnosis. The numeric code
and literal description are required. Use of ICD-9-CM coding is
mandatory.
8. EPSDT Referral - Always check the box "yes".
Family Planning - Check the appropriate box.
Prior Authorization - Leave this space blank.
A. Date of Service - Enter the date of each service provided in
MM DD YY form.
B. Place of Service - Enter the appropriate code for place of service.
Do not use codes C, D, E and F. Use '0' for other location.
PLACE OF SERVICE CODES
IH ‘Inpatient Hospital
OH Outpatient Hospital
0 Doctor's Office
H Patient's Home
- _ pay Care Facility (PSY)
Night Care Facility (PSY)
“Nd °° “Nursing Home .
: Skilled Nursing Facility =
Ambulance
OL Other Locations
IL Independent Labs
ASC Ambulatory Surgical Center
RTC Residential Treatment Center
STF Specialized Treatment Facility
COR Comprehensive Qutpatient Rehabilitation Facility
KDC Independent Kidney Disease Treatment Center on
M
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3-11
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
* C. Procedures, Medical Services or Supplies - A written description of
each service is required. Coding by provider is mandatory. Enter
the appropriate procedure code. ; fe ER rR
* D. Diagnosis Code - Refer to the diagnosis entered .in [tem 23A and
Jndicate the most appropriate diagnosis for each procedure by using
either a 1, 2, 3, or 4. NOTE: More than one diagnosis may be
related to.a procedure (or service). , Do not put ICD-9-CM diagnosis
. -code in this item. eT
= JRC
ERR i 7a
«+ E. Charges - Enter your usual and customary charges for this
0. ._.service/procedure, -s:; --. hn %
—
F. Days or Units - Enter the number of days, quantity “or units
¢ -Tanesthesia) .information, if applicable. | :
G. Type of Service - Leave this space blank.
H. Leave this space blank.
*25, Signature of Physician or Supplier - The claim form must De signed.
Signature stamps or computer generated signatures are acceptable, but
must be initialed. If left blank or if the stamped or computer generated
signature is not initialed, the claim will be returned to the provider.
26. Accept Assignment - Leave this space blank.
*27. Total Charge - Total all charges listed on the claim. If more than one
© Claim form is used, total each claim form separately and do not carry
forward the total charge. :
*28. Amount Paid - If Item 9 is completed showing other health insurance, the
amount paid will be the amount received from other insurance and requires
an Explanation of Benefits (EOB) attached to the claim.
#29. Balance Due - Enter the balance for services listed on the claim form.
If more than one claim form is used, total each claim form separately.
30. Your Social Security Number - Not required for Medicaid.
*31. Physician's Supplier's and/or Group Name, Address, Zi Code and
elephone Number, [.D. No. - tnter ca rovider Number. 1s number
must be entered adjacent to “I.D. NO." If a group provider number has
been assigned, enter only the name of the group and the group's billing
number. This is a seven digit number. poy Tir ;
32. Your Patient's Account Number - If a patient's account (medical record)
number 1s entered, it will appear on the Remittance Advice. It may
consist of letters and/or numbers and may be a maximum of 13 positions.
33. Your Employer I.D. Number : Leave this space blank.
3-12
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
5 : ” HEALTH INSURANCE CLAIM FORM
(CHECK APPLICABLE PROGRAM BLOCK SELOW)
SMES @ SM.OVI0 AN0 COVERED OY tuA Ova
lA 19 TAM .
7 haunt] Alta Ad
HE
LL] ast OF APUUENG FvEICis OR GRIER SIMACE 6 ¢ ABLES HEALTH AADC
TARRY EATS 10 58
9 =.
* MACE OF SEVWCH 400 TV9E OF SERVICE (7 0.5) CUBED GR Tg Sant APPEARED IY Midd, TIRICN, Form WEP hb 08S 0H06 Form OWCP-1980
ER Of MEOICAL, MAMOCE WR Poem CHLMEFRA Foe Rid 908
Figure 3-2. HCFA Claim Form 1500
3-13
Raviced October 9. 1990
Louisiana Medical-Assistance Program
EPSDT Services Provider Manual . .
3.2 PAID CLAIM ADJUSTING/VOIDING INSTRUCTIONS
Only a paid claim can be adjusted or voided.
‘When adjusting a paid claim, never change _ the Provider
Jen: iigasion : Number . or the Recipient/Patient “Identification
Number... .. . or rei oF rs
. 7 For those claim types where multiple services ‘can be billed, the
Adjustment/Void form allows the adjustment -or voiding of only one
—— line on one Adjustment/Void form. . To adjust or void more than one
Tf.
claim line on a multiple line claim form, a separate Adjustment/Void
form is required for each claim line.
“Complete the ~information - on - the -adjustment form exactly as it
appears on the original claim, changing only that item or items that
were in error and giving the reasons for the changes in the space
provided.
To void a paid claim enter all of the information from the original
claim exactly as it appears on the original claim. After a voided
claim has appeared on the Remittance Advice, an original claim can
be resubmitted giving all of the correct information that should
. appear on that claim.
when ‘an Adjustment/Void form has been processed it will appear on
the Remittance. Advice under either Approved or Denied Claims. The
original claim which has been adjusted or voided will appear first
with minus signs. The adjustment or void will appear directly
“beneath the original claim. A voided claim will show zero for the
- payment amount. For an adjusted claim all the correct information
- will appear. This will enable the linkage of the original and the
void or adjustment.
“A Void/Ad justment will generate Credit and Debit Adjustment which
will _appear in the Remittance Summary on the last page of the
Remittance Advice. In this case, debit and credit refer to the
debit against the Medicaid Program and a credit against the Medicaid
_ Program. _
3-14
Revised October 9, 1990
Louisiana Medical Assistance Program .
EPSDT Services Provider Manual ar
3.2.1 EPSDT Screening Adjustment/Void Form (Unisys) 207 Instructions
ADJ/VOID - Check the appropriate box at the top of tha FOr.
>.
x2.
*3e.
*4.
x5
6.
8.
9.
10. Height =" Ledve ‘this ‘space blank, i"
11.
Provider Number - Enter the seven digit Provider Identification Number
which was assigned by MAP. In the case of a Group Practice, enter the
group number. Oh Tor na Tie i
must be voided. ..
> y
Void - Enter the number exactly as it appears on the original
invoice.
Patient's Name
Ad just _ Enter the name exactly as it appears on -the original
invoice.
Void - Enter the name exactly as it appears on the original invoice.
Attending Provider Name - Enter the name of the provider exactly as it:
appears on the original invoice. This name cannot be changed when
adjusting or voiding a claim. : :
Attending Provider Number - Enter the seven digit Provider Identification
Number assigned by the Louisiana Medical Assistance Program. In most
instances, this item will be the same as Item 1. - In cases where a
physician does the screening for the agency or a group practicing member,
that provider number should be entered.
Date of Request - Leave this space blank.
Patient's Address 4
Adjust - This information may be changed when adjusting claims
for correction purposes. ou OE 3%
Void - Enter address exactly as it appears on the original claim.
’
Sex - Leave this space blank. ET
Race - Leave this space blank.
Weight - Leave this space blank.
12. Head Circumference - Leave this space blank.
13. HCT - Hematocrit - Leave this space blank.
"3.15
Roviged Netar lire i
Louisiana Medical Assistance program
EPSDT Services Frovider Manual | :
i ~ Ge 0 Pe tl
14. HEM = Hemoglobin - , Leave hig fpace blank,
—————— rar
15. Firth Weight - - Leave this space blank.
16. Birth Date wth Leave this space blank.
ra a
“17. Blood Pressure -‘ Leave this space blank,
*18. Screening Information -
_ Adjust - This information may be changed. when adjusting a “elaim to
‘make corrections.” - = ; +3 =
Void - Enter this information exactly as. it appears on the original
“IAvaice., *¥ 1" at fe
*19. Screening Results -
Adjust - This information may be changed when adjusting a rain. to
“‘make corrections.
Void - Enter this information exactly as it appears on the original
invoice.
x20. Control Number -
Enter the correct Control Number as shown on the Remittance Advice. This
is always required.
*21. Date of Remittance That Listed. Ctaim Was Paid - Enter date in MM/DD/YY
TOM.
*22. Reasons for Adjustment -
. Check the appropriate box, if applicable, and write a brief narrative
that best describes why this adjustment is necessary,
. *23. Reasons for Void =~ 11%
i.
pr SO
Check the seiropriate box, if Sant i0abte;! and wits a ‘brief narrative
: that best describes why this old is fecessary.,
*24, Date and Signature -
‘ ’ jr, 3 2 . - . * -
LYE ~ ot Vd Giri
Enter current date and signature of authorized representative.”
Jk
*Indicates information which must be coRplett bY the provider before nailing
the claim(s) to the Fiscal Intermediary. :
3-16
Revised October 9, 1990
laniciags ¥- “751 Assistance Program
-:ider Manual
(1) DURING THE 1ST MONTH OF UFE
(2) BETWEEN 8-12 MONTHS OF AGE
(3) AT 2. 3. AND S YEARS OF AGE
(4) AND EVERY 34 YEARS THEREAFTER
Cc SUSPECTED CONDITIONS (NO MORE THAN SIX (6) CAN 8E CHECKED)
o
o
0
0
0
0
0
0
0
0
0
0
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ONEASES OF THE NERVOUS SYSTEM
OAL CRL TRT
PERCTMVE MD FOAM (REASES
COMPUCATIONS OF PREGNANCY. C9LOBIRTH,
AMD THE PUBRPERRAM :
ACCIOMMTE, POMONME. AND WENGE
MATURE OF BUQUIRY)
SPT = 7 * L DEFINED CONDITIONS
DEVELOPMENT. DELAYS
CEASES OF TYE MUSCULOSKELETAL
AO CONNECTIVE THULE SYSTDM
CNEASES OF THE RESPTATORY SYSTEM
CHSAGES OF THE OIGESTIVE SYSTEM
aA
MORE THAN § OF THE ABOVE
Figure 3-3. EPSDT Screening Adjustment/Void Form 207
3-17
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
3.2.2 Health Insurance Claim Adjustment/Void Form 213 Instructions
+1 ADJ/VOID - Check the appropriate box. '™. =
#2. Patient's Name -
_ Adjust "- ‘Enter -the name active as it A0PESrS. on the original
invoice if not 2¢juselng ‘this information. iv =u
eo rs
il Re on 5
ne ad - Enter the name exactly as ir appears | on the oF iia] invoice.
A
3. Patient’ 5 Date of Birth eS pe Eo id hr
a TT a Ie
AF FRE ie ve AEA
fi ise - Enter “the date exactly “as it appears on the original
——————
:
. _ Tnvoice if not adjusting this information. Sar :
Void -"Enter the name exactly as it “appears on the original invoice.
4. Insured's Name - Leave this space blank.
5. Patient's Address and Telephone Number -
Adjust - _Enter the address and telephone number exactly as it
2Ppears on the original invoice if not adjusting this information..
Void - enter the name exactly as it appears on the original invoice.
6. Patient's Sex - Leave this space blank.
*7. Insured’ s 1. D., Medicare and/or Medicaid No. -
Adjust - 1.D. numbers cannot be changed when just ings the invoice
must be voided. weve ;
Void “Enter. the number exactly as it appears on the original
Tmoice. i ’
i patient’ S sat TonshiD to Insured = Higave this space blank. -
a
9. Insured’ Ss Group. No. ~ Leave this space blank,
a —
#10. Other Heal th Insurance Coverage =
SROUR ES. a
BAIS hb hl
wis JAdjust ~- Enter the information exactly as it appears ‘on the origina
invoice if not adjusting the informasion.
T¥old - Enter the information exactly as it appears on the original
~IAVOICR,. mm se mann
Tl ~~ wrt
11. Was Condition Related to: - Leave this sone bank,
12. Insured's Address - Leave this space blank.
13. Date of: - Leave this space blank.
3-18
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
14. Date First Consulted You for This Condition - Leave this space blank.
15. Has Patient Ever Had Same or Similar Symptoms? - Leave this space blank.
16. Date Patient Able to Return to Work - Leave this space blank.
17. Dates of Total Disability - Dates of Partial Disability - Leave this
space blank. ry “3 .
18. Name of Referring Physician or Other Source - Leave this space blank. .
19. For Services Related to Hospitalization Give Hospitalization Dates -
Leave this space blank.
20. Name and Address of Facility where Services Rendered (if other than home
or office) - Leave this space blank.
21. Was Laboratory Work Performed Outside Of Office? - Leave this space
blank. :
22. Diagnosis of Nature of Illness - Leave this space blank.
*23, EPSDT Referral -
Adjust - Enter the information exactly as it appears on the original
invoice if not adjusting the information.
Void - Enter the information exactly as it appears on the original
invoice.
24. Attending Physician - Leave this space blank
*25, A through F -
Adjust - Enter the information exactly as it appears on the original
Tnvoice if not adjusting the information.
Void - Enter the information exactly as it appears on the original
invoice.
*26, Control Number -
The correct Control Number as shown on the Remittance Advice is always
required.
*27. Date of Remittance Advice That Listed Claim was Paid - Enter in MM/DD/YY
form.
*28, Reasons for Adjustment -
- Check the appropriate box if applicable and write a brief narrative that
best describes why this adjustment is necessary.
3-19
Rayigad (rcnher Q. 1940
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
*29,.
*30.
Reasons for Void -
best describes why this void is necessary. ~s
Signature of Physician or Supp fer al
All Adjustment/Void forms ‘must be STohed. BS SL Ewe Ponts
Physician’ s or Supplier’ s Name,’ Address, Zip Code and Telephone -
Enter requested information and the Provider Number of the individual or
--group Provider Number. if billing for a bt LRA
vy YY SER
Your Patient's Account Number - Enter ‘the patient’ Ss correct ‘account
3-20
Revised October 9, 1590
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
007045
SSUASD'S GROUP NO. (OR GACUP NAME)
3
POUAED’S ACORESS (STREET. CITY STATE. DP COO®
NO
PATIENT EYER HAD SAME OR SIMILAR SYMPTOMS?
: BUSTY (ACCIDENT) OR THIS CONOMON
PRGRMANG AIP,
YES
a MD CORES OF FACILITY WHERE SEFACES RENOSIED (¥ OTHER THAN HOME OR OFFICE
Yes
OATES OF PARTWL OIBABIITY
THROUGH
WAS LASORATORY WORK PERFORMED OUTSIDE OF OFFICE”
nO CHARGES
FOR SERACEE RELATED TO NOBITALZATION QivE HOSPTTALZATION DATES
TAGNOES OR NATURE OF ILLNESS. LATE DM@NOSS TO
PROCEDURE I COLUMN O §Y ASPERENCE TO MUMBERS !. 2. 3. OR OX CODE. PET EFTTA. A —————
YES | NO
v
ATTENDING PHYSICIAN (MAME AND MEDICAL Q)
Sor C. AALY OESCANE FRCCEDUASS. MEDICAL SIFWCES OR SUPPLIES ASSERED FOR GON 78 GRE.
> POCO, CODE OLA AIAN. TRPAGTIR OF CLA
0.
Re ant rutt
cool
[
Re lal
s
UIT ros
THB 18 FOR CWMIENND OR VOIIBIS A AWE (TE. (THE CORRECT
COMO. MARER AS SOUR OR NE ARSTTAKE Ave 8
es I.
ET —————.——————
————————
PE -
ia
\ \
\ \
Rl
OR QFRTY
Figure 3-4.
Health Insurance Claim Adjustment/Void Form 213
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
3.3 SUBMISSION OF CLAIM AND ADJUSTMENT/VOID FORMS
a. Screening claim forms (Form 107) and Adjustment/Void forms (Form 207) may
be submitted to:
Unisys/Louisiana Medicaid :
P. 0. Box 91022 i
“Baton Rouge, Louisiana 7082} #
b. Other preventive, follow-up, diagnostic, treatment and health services
—for ~children -with special needs claim forms (Form HCFA "1500) "and
Adjustment/Void forms for these claims (Form 213) may be submitted to:.-.
i ee mre UTSyS Loui Bans eaieavd TE Ed SAT
"9, 0. Box 91020 rat
Baton Rouge, Louisiana 70821 ~ === = «o
"Nr
3.4 CLAIM AND ADJUSTMENT/VOID FORM REQUESTS ae
3.4.1 Claim Form Requests
a. _EPSDT Screening Services
(1) The provider must use a Form 107 "Provider Billing for Screening
Services" format in order to bill for medical screening services.
These may be obtained by writing a request to Unisys or Dy sending
the form, with. quantity required shown opposite to "107-Screening,”
to Unisys. Write to: oe
Unisys/Louisiana Medicaid
8591 United Plaza Boulevard
Suite 100 Te
Baton Rouge, Louisiana 70809
©. ATTENTION: Forms Distribution
(2) The provider must use a Form HCFA 1500, a uniform "Health Insurance
=" Claim Form* format in order to bill for other preventive follow-up,
_ diagnostic, treatment services and services for children with
special needs. HCFA 1500 may be obtained from an office forms sales
a
nd
. ~
atmo
te
-~ oy ant
>. Health Services for Children with Special Needs ~~
3 v2 oo es on + mo
The provider must use a Form HCFA 1500, a uniform “Health Insurance Claim
Form". format in order to bill for health services provided to children
with special needs including children covered under the Education of the
Handicapped Act. HCFA 1500 may be obtained from an office forms sales
office in your area. WLS a
3-22
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSOT Services Provider Manual
3.4.2 Adjustment/Void Form Requests
The provider must use a Form 207 to adjust or void EPSDT Screening Program
claims. - All adjustments or voids to other preventive health, follow-up,
diagnostic, treatment and health services for children with special needs
claims must be made with Form 213 format. These forms should be requested
from Unisys at the address shown above.
3.5 CLAIMS PAYMENT SYSTEM
The purpose of this section is to familiarize the provider with the claims
payment system and the design and content of the Remittance Advice (RA)
document which informs the provider of the current status of submitted claims.
The RA plays an important communication role between the provider, the Bureau
of Health Services Financing, and Unisys. Aside from providing a record of
transactions, the RA assists providers in resolving and correcting possible
errors and reconciling paid claims. - ~
3.5.1 Initial Claims Review
When a claim is received by Unisys, addressed to the proper post office box
for the claim type (see Section 3.3), it will be reviewed for missing data.
If the signature, recipient medical assistance number, service dates, or
Provider Name or Number is missing, the claim will be rejected and returned.
3.5.2 Returned Claims
If the claim is returned because of missing or incomplete items, the original
submitted invoice will be returned accompanied by a Return Letter. The Return
Letter will indicate why the invoice has been returned. Complete the missing
or incomplete items on the original invoice and resubmit it. This is the only
instance where the original invoice is returned to the provider. A returned
claim will not appear on the Remittance Advice because it will not enter the
processing system. oy
3.5.3 Processed Claims
All claims which have been processed will fall into one of the following three
classifications:
:
a. Approved (Paid) a. ATE Chia
b. Pended Be ia Stalls 27 als ;
c. Denied
EE : :
An RA will be sent to the provider after each weekly payment cycle in which a
new claim is processed. Thereafter, each time activity occurs on a claim, an
RA will be issued. grt
3-23
Ravised (October ©. 1990
-
~ e. ~it is a duplicate of a prior claim; _ _
Louisiana Medical Assistance Program _:
EPSDT Services Provider Manual ~~ ~~
3.5.3.1 Approved Claims
A claim which is correctly completed for a covered service provided to an
eligible recipient/patient by an enrolled provider will be approved for
payment and paid. It will appear on the RA on the first page, or pages, which
list all paid claims. If the payment is different from the billed charges, an
explanation will appear on the RA. Te ;
3.5.3.2 Pended Claims
nes, 5 Ef
P nded claims are those claims held for in-house review by the fiscal agent.
If --after. review -it is’ determined that a correction by the provider is
required, the claim will be denied. If the .correction of a claim can be made
during the review, as with a keypunch error, the corrected claim will be paid.
Claims pend for many reasons. ~The following are a few examples:
a. Errors were made in entering data from the claim into the processing
system. “<n :
b. Errors were made in submitting the claim. These errors can only be
corrected by the provider who submitted the claim.
c. The claim must receive medical review.
d. Critical information is missing or incomplete.
3.5.3.3 Denied Claims
Resolving OFS Eligibility File Problems - Errors Codes 215, 216 ro 217
Without proof of eligibility (ID Card, 152N, 110MNP, 6MAP, letter from OFS):
The local OFS must be notified to confirm eligibility for the date of service
and to inform them that claim has been denied because of an eligibility
problem . oi
With proof of eligibility: the claim should be resubmittedwith a copy of the
card or other proof of eligibility attached, and a brief explanation of the
reason the claim was denied. (A copy of the Remittance Advice is sufficient).
A claim will be denied if:
a. the recipient is not eligible on the date of service;
b. the provider is not enrolled on the date of service;
c. prior authorization is required, but not reflected;
d. the service is not covered by the program;
£ -- the date is invalid or logically inconsistent;
g. the program limitations are exceeded;
3.5.4 The Remittance Advice
The Remittance Advice, (RA) informs the provider of the current status of
submitted claims. Claims are listed in sections entitled approved original
claims, adjustment claims, previously paid claims, voided claims, denied
claims and claims in process. On the line immediately below each claim, a
code is printed representing the denial reasons, suspense reasons or payment
3-24
Revised October 9, 13990
Louisiana Medical Assistance Program =
EPSDT Services Provider Manual :
reduction reasons. A literal description of "all reason codes is found on a
separate page following the status listing of the claims... -.
Medicare cross-over claims are listed separately from Medicaid davment oAly
claims. - The heading on" the top .of ‘this Remittance Advice page is
“Institutional” or “Non-Institutional Title XVIII," depending on whether the
claims are processed by the Medicare Part A or Medicare Part B carrier. = -
A Remittance Summary is found at the end of the Remittance Advice. This is a
summary of the claim activity for the weekly checkwrite, e.g. reimbursement to
the provider. The number and dollar value of all claim transactions are
displayed as well as total payment, check number and year-to-date ‘payment.
Financial transactions other than claim transactions are listed on a separate
page. Refunds, audit payouts and recoupments "will be noted on ‘the line
immediately below each claim. A code is printed representing denial reasons,
suspense reasons and payment reduction reasons. Messages explaining all codes
found on the RA is found on a separate page following the status listing of
all claims.
Pat aly
Internal Control Number (ICN)
A unique 13 digit I.D. number, called the Claim Control Number (ICN), is
assigned to each claim. The claim control number reflected on the Remittance
Advice may be used to track the status of a claim from receipt to final
adjudication. - : :
The first four digits of the control number are the actual year and date the
claim was received. The next seven digits indicate whether the claim was
received on paper or tape and then reflects the batch and sequence numbers of
the claim's entry into the processing system. All claim lines on a given
claim form will have the same first 11 digits. The last two numbers will help
to determine which line of a claim form is being referenced:
Example: 1365023456700 - refers to first claim line
1365023456701 - refers to second claim line
1365023456702 - refers to third claim line
For those claim types which are not processed by line (inpatient hospital,
screening and pharmacy), the ICN for the claim always ends in 00. The ICN on
all multiple-line claim forms with just one service billed on line 0 also ends
in 00. Figure 3-5 is a sample Remittance Advice.
when a medical record number is used (it may consist of alpha and/or numeric
characters), it appears on the line immediately below the recipient's number.
3-25
2 eg 7 EEN 0
Louisiana Medical Assistance Program
EPSOT Services Provider Manual = °°
3.5.5 Unisys Provider Relations
Unisys has a provider relations staff readily available to assist providers
with their billing questions and concerns. There are Unisys staff located in
the Baton Rouge office whose primary responsibility is to respond to telephone
inquiries. . Providers may contact Unisys Provider Relations Unit by calling
one of the following telephone numbers. . . Pl i
924-5040
og ol § - . >;Baton Rouge Area . .. ..:
.- -New Orleans Area’ _._.. .... ghee 528.9846 © |v 3.NESIiE
ts TIA a 17m: NI RumraGO)TaT- 047 22 tion aed Be pm
This service is available Monday through Friday from 8:00 a.m. to 5:00 pum.
Written inquiries should be addressed to: :.
“Unisys ii kad
ATTN: Provider Relations
P.0. Box 4169
Baton Rouge, LA 70821
Provider Relations representatives are also available to visit a provider's
office to help with billing problems or to help train new staff. They may be
contacted at one of the telephone numbers listed above to arrange for a visit.
Written inquiries should contain a note or letter describing the problem.
Inquiries submitted without explanations could be processed without additional
consideration. = i... |
3-26
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
3.6 REFUND PROCEDURE
Re funds should generally be made by submitting an adjustment or void in
accordance with billing procedures.
when making refunds by check, identify the claim or claims to which the refund
is applied. The information necessary to identify these claims will help to
reduce additional correspondence. This information may be found on the
Remittance Advice.
a. ~ Provider Number -- - -— on ER i mn
b. Date of Payment
c. Control Number ba a a ne SILI
d. Recipient Name and Identification Number hE
e. Date of Service - i si PARE
fe. Amount Paid
g. Reason for Refund. =
Refunds should be made payable to Department of Health and Hospitals at the
following address:
4
Financial Management Section
Bureau of Fiscal Services
P. 0, Box 3797
Baton Rouge, Louisiana 70821-3797
3-27
13 end Arh Fath i Q. Jacn
Louisiana Medical Assistance Program
EPSDOT Services Provider Manual = ~-
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Figure 3-5. Remittance Advice
43.28
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
4. FRAUD AND ABUSE
4.1 GENERAL
Federal regulations require that Medical Assistance Program establish criteria
for identifying situations in which there may be fraud, or abuse, arrange for
prompt referral of such authorities, and develop methods of investigation or
review that ascertain the facts without infringing on the legal .rights of the
individuals involved and that are consistent with principles recognized as
affording due process of law. Fe
Fraud is determined ‘in accordance with State and Federal law. Abuse is
determined by review of service utilized and the appropriateness of such
services as recognized under program regulations and accepted medical
practices, TE or Le Tee at aa, Wy
4.2 ‘TYPES OF FRAUD AND ABUSE
‘3.2.1 Fraud
Fraud, in all of its aspects, is a matter of law. The definition of fraud
that governs between citizens and government agencies is found in Louisiana
R.S. 14:67 and Louisiana R.S. 14:70.01. Legal action may also be mandated
id Section 1909 of the Social Security Act as amended by Public Law 95-142
HRO3). ; :
Prosecution for fraud and the imposition of a penalty, if the individual is
found guilty, are prescribed by law and are the responsibility of the law
enforcement officials and the courts. All such legal action is subject to due
process of law and to the protection of the rights of the individual afforded
by this process.
4.2.1.1 Provider Fraud
Cases involving one or more of the following situations shall constitute
sufficient grounds for a provider fraud referral:
a. Billing for service, supplies or equipment which are not rendered to, or
used for, Medicaid patients. Le :
b. Billing for supplies or equipment which are clearly unsuitable for the
- patient's needs or are so lacking in quality or sufficiency for the
purpose as to be virtually worthless. Be ro
Claiming of costs for noncovered or non-chargeable services, supplies, or
equipment disguised as covered items. :
,
Material misrepresentations of dates and descriptions of services
rendered, or of the identity of the recipient or the individual who
rendered the services.
Duplicate billing of the Medicaid Program or the recipient which appears
to be a deliberate attempt to obtain additional reimbursement.
Louisiana Medical Assistance Program
EPSDT Services Provider Manual i
fe Arrangements by providers with employees, independent contractors,
suppliers, and others which appear to be designed primarily to ‘obtain
additional reimbursement from the Medicaid Program by various devices
~ (commissions, fee splittings) used to obtain or conceal illegal payments.
4.2.1.2 = Recipient Fraud
Cases involving one ‘or more of the following situations shall constitute
sufficient grounds ‘for a recipient fraud referrals 7 o-oo 0 Lo bs ol ges
a. The misrepresentation of facts in order to become or remain eligible to
“receive benefits ‘under the Medicaid Program or misrepresenting facts in
"order to obtain greater benefits once detlared eligible. - :
: ee Fed SH 42 HPAI. dh FH Be Te I Sot vt 1 inte 4 p=
b. The transferring by a recipient of a medical eligibility card to a person
not eligible to receive services under MAP or to-a person whose benefits
have been restricted or exhausted; thus enabling such a person to receive
unauthorized medical benefits. : i
c. .The unauthorized use of a medical eligibility card by persons not
eligible to receive medical benefits under Medicaid.
4.2.2 : Abuse
Abuse by either providers or recipients denotes practices which under initial
review indicate not substantial potential for criminal prosecution and which
may even be technically legal, but which are still inappropriate uses of
public funds. rosa
4.2.2.1 Provider Abuse
Cases involving one or more of the following situations shall constitute
sufficient grounds for a provider abuse referral:
a. The provisions of services that are not medically necessary.
b. .Flagrant and persistent overutilization of medical or paramedical
services with little or no regard for results, the patient's ailments,
condition, medical needs, or the doctor's orders.
Co “The unintentional misrepresentation of dates and descriptions of services
“rendered, or of the identity of the recipient or the individual who
rendered the services in order to ~gain . greater reimbursement than
entitled. ;
4.2.2.2 Recipient Abuse
Cases involving one or more of ‘the following situations shall constitute
sufficient grounds for a recipient abuse referrals. ©.
a. .Unnecessary or excessive use of the prescription medication benefits of
MAP. : : : 6 Ws $35 ? i * . .
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
b. Unnecessary or excessive use of the physician's visits benefits of
. Medicaid. . i 7
Ca Unnecessary or excessive use of other medical services and/or medical
supplies that are benefits of Medicaid. = =
4.3 FRAUD AND ABUSE DETECTION wie ERTL
4,3.1 Referrals
Situations involving potential fraud and/or abuse which are to be followed up
for review by the Bureau may include any or all of the following:
a. Complaints or reports by mail, telephone, or in person.
b. Cases referred by the U. S. Department of Health and Human Services.
(The Bureau in turn refers suspected cases of fraud in the Medicare
Program to the Health Care Financing Administration (HCFA) and works very
closely with that agency in such matters.)
Ce Situations brought to light by special review, internal controls or
provider audits or inspections.
d. Referrals from other agencies or sources of information.
4.3.2 ~~ Recipient Verification Notices (REOMBs)
The Federal regulations (Public Law 92-693, Sec 253 (3) for MMIS require that
the Bureau provide prompt written notice to individuals who are furnished
services covered under Medicaid of the name of the person or persons
furnishing the services, the date on which services were furnished, and the
amount of payment. A predetermined percentage of the recipients who had
medical services paid on their behalf during the previous month will be
receiving the required notice, {.e., the Recipient's Explanation of Medical
Benefits (REOMB). From time to time, BHSF may send notices to 100 percent of
the recipients receiving services for any provider for any given period.
The REOMB contains the following information:
a. Recipient Medical I.D. Number |
b. Recipient Name Sg Kop
c. Date of REOMB (monthly, on the 15th)
d. Dates of Service Provided
e. Narrative description of services
f. .Place of Service ed
g. Provider of Services
h. Amount paid by Medicaid
On the reverse side of the REOMB, preprinted instructions request the
recipient to identify any service that is listed which was not received (or
for which payment was required), to write a brief explanation with recipient's
phone number, and to return the REOMB to the Fiscal Intermediary, postage
paid.
4-3
Davicad Netnher 9. 1990
Louisiana Medical Assistance Program
EPSOT Services Provider Manual
The fiscal intermediary researches claim copies and provider remittance
documents to assure that the recipient, provider, and services on the returned
REOMB were accurately presented. If the information was inaccurately listed
on the REOMB, the REOMB and .all documentation is reviewed by the Unisys
Surveillance Utilization Review System (SURS) Unit. ~~ Ee 0 gl 3
The situations meriting further inquiry are reviewed by SURS. Those
situations meriting further criminal investigation will be “referred ‘to the
State Attorney General's Medicaid Fraud Control Unit.
4.3.3 Computer Profiling
The fiscal intermediary's format system generates profile reports on providers
and recipients which identified potential fraud and abuse situations.
A profile report is a computer generated document which is produced from data
gathered in the State's claims paymeat operation. . Participants are classified
into peer groups according to geographic location, medical specialties, or
categories as developed. These reports include: is 38 : :
a. A statistical profile of each peer group classification to be used as a
base line for evaluation; :
b. A statistical profile of each individual participant compatible with the
peer group profile;
Evaluation of each individual participant profile against its appropriate
group profile; - :
d. A listing of individual participants who deviate significantly from their
group norm, reported as exceptional and flagged for analysis;
Each exceptional profile is subjected to review and analysis by trained staff
assisted by medical consultants to determine the cause of exceptions. The
analysis can include a review of the provider's paid claims, a review of the
provider's reply to the agency's written request for information,:a review of
hospital charges and patient records obtained in field reviews and a review of
other relevant documents. The review is not necessarily limited to
exceptional areas identified on the profile report. * ie he
4.4 ADMINISTRATIVE SANCTIONS
4.4.1 General dE oe oS ie Rk “od > 5 ree E av
Medicaid payments are subject to review by the Bureau to ensure the quality,
quantity, and need for services. Administrative sanctions may be imposed
against any Medicaid provider who does not meet the guidelines as ‘listed ‘in
the following section. Administrative sanction means ‘any administrative
“action applied by the single state agency against a medical service provider
of Title XIX services - which is designed to remedy inefficient and/or illegal
practices which are not in compliance with the Louisiana Medicaid policies and
procedures, statutes, and regulations. - if alae rian
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider Manual
4.4.2 Levels of Administrative Sanctions
Listed below are the levels of administrative sanctions which the Bureau may
impose against a Medicaid provider. : poss es : : :
a. Give warning through written notice or consultation; -
b. Require education in program policies and billing procedures;
Ce Require prior authorization of services; :- nr agit
d. Place claims on manual. review before payment is made;
: ‘ fa a LE » 2 v bi - me spin
.. Any provider of Medicaid Services may be placed on prepayment review as
an administrative sanction for misutilization of the Medicaid Program.
Prepayment review may be limited to those types of procedures for which
misutilization has been detected or it may include a 100 percent review
of the provider's submitted claims." STE
e. Suspend or withhold payments.
The Bureau may suspend or withhold payment to any provider who fails to
meet the requirements for participation in Medicaid Program.
f. Recover money improperly or erroneously paid either by deducting from
future billings or Dy requiring direct payment.
g. Refer to the appropriate State Licensing Authority for investigation.
h. Refer for review by appropriate professional organizations.
i. Refer to the Attorney General's Medicaid Fraud Control Unit for fraud
investigation, Hache TE
j. Suspend participation in the Medicaid Program.
k. Refuse to allow participation in the Medicaid Program.
4.4.3 Grounds for Sanctioning Providers
The Bureau may impose sanctions against any provider of medical goods or
services if the agency finds: 1k : = a :
a. A provider is not complying with -the agency's policy or rules and
regulations, or with the terms and conditions prescribed by the agency in
its provider agreement and signed claim setting forth the terms and
conditions applicable to the participating of each provider group in the
program; : biped: Sg CR ar Loy
b. A provider has submitted a false or fraudulent application for provider
status;
c. Such provider is not properly licensed or qualified, or such provider's
professional license, certificate or other authorization has not been
renewed or has been revoked, suspended or otherwise terminated.
4-5
Revised October 9, 1990
Louisiana Medical Assistance Program :_
EPSDT Services Provider Manual :2 [i
d. Such provider has engaged in a course of conduct or has performed an act
for which official sanction has been applied by the licensing authority,
professional peer group or peer review board or organization .or
continuing such conduct following notification by the licensing or
reviewing body that said conduct should cease.
Such provider has failed to correct deficiencies in his delivery of
service or billing practices after having received written notice of
these deficiencies from the Bureau. : "= in Rt WL :
Such provider has been excluded from participation in Medicare because of
fraudulent or abusive practices pursuamt to Public Law 95-142, or such
provider has been convicted of Medicaid fraud. (Louisiana R.S. 14:70.1).
g.
‘Such prov
performance of a provider agreement with the agency or of fraudulent
@ ~ pile Ba. AF 2%. iA
ider has been convicted of .a criminal -offense relating to
billing practices or of negligent practice resulting in death or injury
to the provider's patient. : |
Such provider has presented or has caused to be presented any false or
fraudulent claim for services or merchandise for the purpose of obtaining
greater compensation than to which the provider is legally entitled.
Such provider has engaged in a practice of charging and accepting payment
(in whole or part) from recipients for services for which a charge was
made to the agency and payment was made by the agency.
Such provider has rebated or accepted a fee or portion of fee or charge
for a patient referral. 4
Such provider has failed to repay or make arrangements for the repayment
of identified overpayment or otherwise erroneous payment.
Such provider has failed after receiving a written request from the
agency, to keep or make available for inspection, audit or copying, such
records regarding payments claimed for providing services.
Such provider has failed to furnish any information requested by the
agency regarding payments for providing goods or services.
Such provider has made, or caused to be made, any false statement or
representation of a material fact in connection with the administration
of the Medical Assistance Program. = = :@ °° <° = gh
Such provider has furnished goods or services to a recipient which are:
(1) in excess of his. or her needs; (2) harmful to the recipient; or (3)
of grossly inadequate or inferior quality, all of such determinations to
be based upon competent medical judgment and evaluations. - :
Revised October 9, 1990
OW
Louisiana Medical Assistance Program
EPSDT Services Provider Manual -
Pe The provider; a person with management responsibility for a provider; an
officer or person owning, “either directly or indirectly, five percent or
more of the shares of stock or other evidences -of -ownership in a
corporate provider; an owner of a sole proprietorship which is a
- provider; or a ‘partner in a partnership which is a provider, either:
(1) was previously determined to be barred -from participation in the
p Medical Assistance Program; or
3 Ea - <7 1s i - eo -~ = oe - HE
ES" ml
pou
“{(2) was" a ‘person “with management -~responsibility ‘for ..a previously
terminated provider during the time of conduct which was the basis
for” that “provider's termination :from participation in the Medical
Assistance Program; or. : BYE a
(3) was an officer, or person owning either directly or indirectly, five
percent or more of - the “shares of stock or. other. evidences of
ownership in a previously terminated corporate provider during the
time of conduct which was the basis for that provider's termination
from participation in the Medical Assistance Program; or :
(4) was an owner of a sole proprietorship or partner of a partnership
which was previously terminated during the time of conduct which was
the basis for that provider's termination from participation in the
Medical Assistance Program. ay AS oi
q. The provider; a person with management responsibility for a provider; an
office or person owning, either directly or indirectly, five percent or
more of the shares of stock or other evidences of ownership in a
corporate provider; an owner of a sole proprietorship which is a
provider; a partnership which is a provider; or a partner in a
partnership which is a provider, either:
(1) has engaged in practices prohibited by federal or state law or
. regulation;
(2) was a person with management responsibility for a provider at the
time that such provider engaged in practices prohibited by federal
or state law or regulation;
(3) was an office, or person owning, either directly or indirectly, five
percent or more of the shares of stock or other evidences of
ownership in a provider at the time such provider engaged in
practices prohibited by federal or state law or regulation;
(4) was an owner or a sole proprietorship or partner of a partnership
which was a provider at the time such provider engaged in practices
prohibited by federal or state law or regulation;
r. The provider; a person with management responsibility for a provider; an
officer or person owning; either directly or indirectly, five percent or
more of the shares of stock or other evidences of ownership in a
corporate provider; an owner of a sole proprietorship which is a
provider; or a partnership which is a provider; or a partner in a
partnership which was a provider, either:
:
4-7
Revised October 9, 1990
Louisiana Medical Assistance Program
EPSDT Services Provider ‘Manual
(1) “has been convicted of Medicaid fraud under federal or state law or
“‘regulation; Sn 1 REE SAE AEST pon HORE Lhe +g ET :
(2) was ‘a person with ‘management - responsibility for a provider at the
time such provider was convicted of Medicaid fraud under federal or
state law or regulation; fo i rey
(3) was an office, or person owning, either directly or indirectly, five
YE = percent or more “of .the shares of -stock -or. other . evidences of
°"- ownership in a provider at the time such provider was convicted of
‘Medicaid fraud under -federal or state law or regulation;
(4) _was an owner of a sole proprietorship or partner of a partnership
7 which ‘was a provider at the time such provider was convicted of
Medicaid fraud under federal or state law or regulation.
~
4.5 FAIR HEARING (APPEALS)
The Louisiana Department of Health and Hospitals, provides opportunity for a
hearing to any provider who feels that he/she has been unfairly sanctioned.
The Bureau of Appeals in the Department of Social Services is responsible for
conducting hearings relating to provider complaints. Detailed information
regarding the appeal procedure may be obtained from the Bureau of Appeals at
_ Post Office Box 94065, .Baton Royge, Louisiana 70804. Requests for hearings
should be made in writing directly to the same address explaining the reason
for the request. : di :
4-8
Revised October 9, 1990
(of.