Early and Periodic Screening Diagnosis and Treatment - Special Processing and Medical Vendor Payments (Reissue)

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~: . MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

19-610 IN GENERAL 

PART XVIII. EARLY AND PERIODIC SCREENING, 
DIAGNOSIS AND TREATMENT PROGRAM (EPSDT) 
  

  

A. Screening, Diagnosis and Treatment of Physical and Mental Defects for 
  

Individuals Under 21 
  

The Medicaid (Title XIX) Program provides early and periodic screening 
and diagnosis to ascertain physical and mental defects, and treatment of 
conditions discovered within the limits of the medical assistance program. 
These services are available to all eligible individuals under 21 years of 
age and in addition, eyeglasses, hearing aids, other kinds of treatment for 
visual and hearing defects, and dental care as is necessary for relief of 
pain and infection and for restoration of teeth and maintenance of dental 
health. 

The Office of Family Security (OFS) is responsible for administering 
the EPSDT program under Title XIX. For recipients in private and state- 
operated ICF/H facilities, the Regional Office Staff is responsible for 
performing EPSDT referrals for dental services, eyeglasses and other 
appliances. 

OFS has arranged with the Office of Health Services and Environmental 
Quality (OHSEQ), New Orleans City Health Department and the Department of 
Education to deliver the screening services for all eligible children as 
well as diagnostic and treatment services which are available within their 
program. Any additional diagnostic and treatment services needed are 
arranged for by referral to the private sector or to the Charity Hospital 
System. Billing for all services provided by the private sector and the 
Charity Hospital System including dental services, eyeglasses, etc., are 
billed directly to the Office of Family Security's fiscal intermediary. 

Definitions 
  

(1) Request for EPSDT services may be an unsolicited inquiry by a client 
for services, or a positive response by a client to an inquiry or an 
offer of screening services. . 

  

Screening is the use of a quick, simple procedure carried out among 
large groups of people to sort out apparently well persons from those 
who have a disease or abnormality and to identify those in need of 
more definitive study of their physical or mental problems. The pre- 
sence of a physician is not required during the screening procedure. 

  

  El Reissued January i Page 1 of 19-610 
Replacing June 1, 1 i  



  

  
  

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening 

Diagnosis and Treatment 
* 
  

(3) Diagnosis is the determination of the nature or cause of physical or 

mental disease or abnormality through the combined use of health 

history, physical, developmental and psychological examination, and 

laboratory tests and X-rays. Although, in some instances, a 

presumptive diagnosis may be made at the time of screening, it will 

usually be necessary to refer the patient to the appropriate 

practitioner or medical facility for definitive evaluation. 

  

(4) - Treatment means physician's or dentist's services, optometrist's 

or audiologist's services, hospital services (inpatient or outpatient), 

clinic services; laboratory and X-ray services; prescribed drugs, 

eyeglasses, hearing aids, prosthetic or orthotic devices, rehabilita- 

tion services including physical therapy, occupational therapy, speech 

pathology and audiology services to prevent, correct or ameliorate 

disease or abnormalities detected by screening and diagnostic 

procedures and limited to Louisiana Medicaid Program for medical 

services. 

  

(5) Early means, in case of a family already receiving assistance, as 

_early as possible in the child's life; or as soon as a family's 

eligibility for assistance has been established. 

(6) Periodic means at intervals established for screening by medical, 

dental and other health care experts at appropriate periods of time 

to assure that disease or disability is not incipient or present. 

  

  

  

  

  

19-611 WHO IS ELIGIBLE 

Rev. * All persons who are under 21 years of age and identified in Section 

*%* 19-105 A are eligible for EPSDT services. 

19-612 IDENTIFICATION OF ELIGIBLES 

Persons eligible for EPSDT services are identified by an asterisk which 
is placed by their name on the Louisiana Medical Eligibility Card, Form 9. 

19-613 STEPS TO BE TAKEN IN ARRANGING FOR EPSDT SERVICES 

Rev. * A. State Office Responsibilitv 

The Office of Family Security is responsible for the overall administration 

of the EPSDT Program as follows: 

(1) Coordinating activities of the providers of services to EPSDT 

children. 

(2) Updating the Operational procedures. 

(3) Monitoring the performance of providers of services. 

(4) Authorizing payment via cost reports and audits. 

Issued January |, 1983 19-610; 19-613 

 



  

  

MEDICAL VENDOR PAYMENTS : Early and Periodic Screening 

Diagnosis and Treatment 

  

B. Local Office Responsibility 
  

Each local OFS is responsible for informing newly certified 

recipients of the services available through the EPSDT Program. 

Clients will be informed within 60 days of becoming eligible. In 

addition to the verbal explanation, the client shall be given a copy of 

The informing will be accomplished in the following steps: 

(1) 

(2) 

(3) 

Eligibility Worker 
  

A face-to-face contact shall be required for the purpose of 

explaining the EPSDT Program for newly made eligibles. This 

explanation shall be required only at application or 

reapplication. The Eligibility Worker shall verbally and in 

5 EPSDT) communicate the facts about the program and 

  

  

Monthly List 
  

A list of those certified monthly will be supplied by the 

local office to the Community Activity Worker(s) (CAW) so that 

they can fulfill the second part of the informing process, 

that of determining if a client wishes to participate in the 

program. If a client indicates the necessity of a medical or 

dental appointment sooner and appears eligible, special effort 

should be made to have the CAW schedule as a top priority. 

Community Activity Worker 
  

The Community Activity Worker, upon receipt of the monthly 

certification list, shall make the following arrangements for 

an EPSDT initial screening appointment: 

(a) Pull the case record. (There should only be one record). 

(b) Contact the client(s) by telephone within sixty (60) days 

of the certification date to inquire about their interest 

in the program and to make a specific offer of both 

dental and medical EPSDT services. A CR-8 entry shall be 
  

made recording the telephone contact. The certification 

date, for Federal purposes, is the date the case_   

  

Reissued November 1, 1987 
Page 2 of 19-613 

Replacing January 1, 1983 issue 

 



     
MEDICAL VENDOR PAYMENTS Early and Periodic Screening 

Diagnosis and Treatment 

  

(ec) 

(d) 

(e) 

(£) 

(g) 

(h) 
Rev. = 

scheduling and transportation. 

In cases where the client(s) cannot be contacted by 

telephone, the CAW will send a form letter (EPSDT Form 8) 

which explains the programs and contains the local 

offices' phone numbers. The CAW shall enclose in the 

form letter a self-addressed return envelope for the 

client's use. A CR-8 entry shall be made when the form 

letter is mailed. The client may either call or return 

‘the letter to request EPSDT services. 

  

  

In no instances shall the CAW schedule a screening 

without the client being contacted verbally or in writing 

and without securing the client's request for screening. 

The CAW will record acceptance of EPSDT screening on the 

Form 23 EPSDT which will serve as the documentation 

instrument for the client's acceptance of the services. 

for screening services. Note: Whenever a Form 23 _EPSDT 

is completed, the CAW will also_complete Items 25_and_26 

on_page 2 of Form L'AMI-1. 

The CAW shall follow federal regulations that mandate a 

child requesting medical screening or dental services 

shall have these services provided within 120 days of the 

date of request. This means that the child should have 

had a medical screening or dental screening appointment 

made within that time frame. In the case of medical - 

screening, if a referral for treatment is made, treatment 

purposes, will commence on the date the client requests 

the service. It is imperative that this date be clearly 

All copies of correspondence to the client shall be filed 

in the correspondence section of the case record. This 

includes copies of the EPSDT Form 8, 23 EPSDT and Forms 

14-D from screening providers. 

Declinations of the offer of EPSDT services shall be 

recorded by the CAW on the CR-8, and an entry shall be 

made to the computer system, reporting code 4 in Item 25 

and the current date in Item 26 on page 2 of Form 

L'AMI-1. 

  

Reissued November 1, 

Replacing January 1, 

  

1987 
Page 3 of 19-5613 

1983 issue



   
£
7
 

L 

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 

Diagnosis and Treatment 

  

(1) 

(3) 

In three parishes, Orleans, Jefferson and Plaquemines, if 

the client requests dental services, the CAW shall 

provide a dental referral form which the client takes to 

the dental office at the time of the initial 

appointment. A designated person in the local office 

will be responsible for issuing these forms upon the 

client's request. If the local office quota is 

exhausted, clients will be referred to the appropriate 

alternate screening agency to secure dental referral 

forms. Alternate screening agencies are Parish Health 

Units and, in certain participating parishes, the School 

Nurse Program. 

If the child is already in screening, Form 23 EPSDT is 

not completed. An entry shall be made to the computer 

system, reporting code 5 in Item 25 and the current date 

in Item 26 on page 2 of Form L'AMI-1. 

(4) Transportation 
  

(a) 

(b) 

OFS will provide transportation when possible to EPSDT 

clients who request transportation. 

If a client needs transportation, but OFS is unable to 

provide it, assistance will be given to arrange 

transportation through a third party. 

  

Issued November 1, 1987 Page 3a of 19-613 

 



= 

  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
: Diagnosis and Treatment 
  

  

(. (5) EPSDT Follow-Up Services 

(a) The CAW is expected to follow-up on cases in which a client 
has missed an EPSDT screening appointment and is identified 
in writing from OHSEQ or New Orleans City Health Department. 
If a client misses the first appointment, contact shall be 
made by letter from the CAW advising the client to contact 
the local office if interested in rescheduling. There will 
be only one rescheduling unless screening is requested at a 
later date. : 

(b) The CAW will be responsible for medical follow-up on those 
cases identified by OHSEQ, New Orleans City Health Department 
or a Parish School Board by a Form 14-D. as needing assistance 
in obtaining the necessary medical care. : 

The Form 14-D, the communication mechanism used by screening 
providers to notify CAW's of client's request for ‘assistance 
in keeping medical or dental appointments, is to be ordered 
and stocked by the local OFS.. These forms will be supplied to 
the screening providers upon request. : 

(6) Arrangements for Periodic Screening 
  

(a) The CAW will contact either verbally (preferred) or in writing 
(if client has no phone) the clients identified by screening 
providers as being in need of rescreening according to the 
periodicity schedule. 

(b) In most parishes throughout the state, OHSEQ advises the local 
offices when an EPSDT eligible is due for rescreening according 
to the periodicity schedule. : 

(c) The EPSDT Periodicity Schedule is as follows: 

Eligible persons shall be scheduled for screening services, 
if not under regular medical care at the following ages: The 
first screening may occur at any time during the first month of 
life between 8-12 months of age; at 2, 3, and 5 years of age and 

* every three (3) years thereafter- 

C. Office of Health Services and Environmental Quality (OHSEQ). New Orleans 
City Health Department and Department of Education Responsibility 
  

  

The Office of Health Services and Environmental Quality, New Orleans 
City Health Department and Department of Education are responsible for 
providing health services to clients in the screening process. They are 
also responsible for continuing involvement in the treatment process. 
This includes determining what resource a client needs and desires to 
be referred to, obtaining the initial appointment for the client, 
requesting a report from the referral resource, and keeping the local 
OFS office informed as to the appointment dates secured for the clients 
requiring assistance. The local OFS office will provide the necessary 

  

Reissued January 1, 1983 Page 4 or 19-513 
Replacing June 1, 1979 issue 

 



  

  rem 

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
( : Diagnosis and Treatment 
  

help in arranging or providing transportation and other supportive services in 
order to help the client continue with the diagnosis and treatment process. 

(1) Diagnostic and Treatment Follow-Up 
  

Rev. * Follow-up is the key to determining if children identified in 

screening as having referable condition receive further diagnosis 

and treatment. The responsibility for follow-up shall Be shared 

by the Office of Family Security, Office of Health Services and 

Envirommental Quality, New Orleans City Health Department and 

od Department of Education. 

  

- Medical follow-up shall be accomplished by OHSEQ, New Orleans City 

Health Department Clinic, and Department of Education staff securing 

results of referrals to clinics within OHSEQ, the New Orleans City 

Health Department and the private sector. The procedure to be used 

is as follows: 

  

Rev. * : ~ (a) - If the client -has a referable condition, the local health 

facility shall, if the client concurs, schedule an appointment 

with a provider of the client's choice for further diagnosis 

and treatment. A Form 14-D shall be completed and submitted to 

the local OFS on those clients in need of assistance with trans- 

portation or other supportive services to enable the client to 

73 keep the appointment. 

  

The clients shall schedule appointments for themselves when they 

elect not to have the health facility schedule it for them or 

when they choose to receive diagnostic and treatment services from 

a State Charity Hospital and it is logistically impossible on the 

screening clinic date to obtain that appointment. It shall be 

the responsibility of the health facility to complete and forward 

“to the local office a Form 14-D on those individuals requiring 

. assistance to keep these appointments. It shall be the responsi- 

bility of the local staff to contact those clients regarding the 
date and the time of the appointment for purposes of follow-up. 

(b) The local worker shall completé Form 14-D and send to the local 

health facility advising whether the client (a) kept the appoint- 

ment, (b) did not keep the appointment, or (c) was rescheduled 

to another date and time and the worker provided transportation. 

If an appointment is scheduled with another provider on the 
same date or within a few days of the clinic date, and the lo- 

cal health facility knows that processing the Form 14-D through 

regular mail will not allow sufficient time for the local OFS 
to plan for meeting transportation and other supportive needs, 

the local health facility shall notify the local OFS by telephcne. 

The Form 14-D shall be forwarded to the local OFS within S days 

of the clinic and will give the medical reason for the referral, 

the appointment date and time, and the name of the provider to 

** whom the client was referred. 

  

Reissued January |, i933 Page 5 of 19-013 

Replacing June 1, 1979 issue 

 



  

  

Early and Periodic Screening 
MEDICAL VENDOR PAYMENTS = = 8 | Sih Diagnosis and Treatment 

( : | 
ih (¢) Within 10 working days of receipt of Form 14-D from the local OFS 

; that the client kept the scheduled appointment, the local 

health facility shall request a report from the referral 

resource. - 

  

Rev. * (2) Office of Health Services and Environmental Quality (OHSEQ), New 

Orleans City Health Department, and Department of Education 

Documentation 

  

  

  

OHSEQ, New Orleans City Health Department and Department of 

Education shall make available to State OFS their plan, based on 

documentation requested below, on how the patient's record will 

be kept. 

(a) Office of Health Services and Environmental Quality 
  

(i) Completion of the appropriate claim for allowable services. 

(11) Completion of the appropriate OHSEQ Personal Health 
- Records to reflect services provided. 

(b) New Orleans Citv Health Department 
  

- 

(1) Completion of the appropriate claim for allowable services. 

rd : (ii) Completion in full of City Health Department Clinic 
“Encounter Form. 
  

(c) Department of Education 
  

(1) Completion of the appropriate claim for allowable services. 

(ii) Completion of all screening components contained in Basic 
Screening Package. 

(d) Items Which All Medical Providers 

Above Shall Include in Their Documentation 
  

  

(i) Notation if required service was not received and why it 

was not received. 

(ii) Date child to be rescreened (periodicity) to be noted. 

(iii) Date seresntos package components received by client. 

(iv) Diagnosis and treatment services arranged. 

(v) Date diagnosis and treatment services received. 

(vi) Transportation and/or support services discussed and 

referred to OFS. 

(vii) Copy of Form 1l4-D sent to OFS. 

  

Reissued January |, 1983 Page 6 of 19-613 

Replacing June 1, 1979 issue 

 



  

  

MEDICAL VENDOR PAYMENTS : Early and Periodic Screening 

. Diagnosis and ‘Treatment 
' 

  

=
 (viii) Number ‘of individuals scheduled to receive EPSDT services, 

and number due this quarter for assessment or reassessment 

according to periodicity schedule. 

  

Total Under 1 1-5 6-12 13-17 18-20 

              
  

(ix) Copy of the report from the referral resource regarding 

li diagnosis and treatment is required when referral is made. 

D. Department of Education Responsibilities 
  

specified below: 

(a) School age children not previously screened by OHSEQ. This 
will include children presently being followed in Family 
Planning Clinics who have not been previously screened. 

  

®) Periodic screening of school age children 11 years of age or 
older even though the initial screening may have been performed 
by OHSEQ. 

An exception to the above would be when a child is being fol- 
lowed by QHSEQ for a specific condition, e.g., sickle cell 
disease or trait, tuberculosis, or is being followed in the 
Handicapped Children's Program. : 

Periodic screening of children below the age of 11 will be 

determined on a parish by parish basis by OFS, OHSEQ, and 
Department of Education. The school nurse shall notify the 
health unit if she is unable to screen the school age child 
when periodicity is due. It will then be the health unit's 

(c) The Department of Education is responsible for the periodic 

progressing to lower grades as secondary school age children are 

screened. 

Rev. * (3) In order to avoid duplicate screenings, the school nurse should 

determine whether a child has been screened previously. They are 

required to secure a written parental consent to perform certain 

health procedures. School nurses in the 15 EPSDT School Nurse 

Programs will contact the local office to provide copies of ''paren- 

tal consent forms." The Eligibility Worker shall have the client 

sign a form for each schocl age child in the home. The form shall 

be clipped in the record. When the CAW makes the referral to the 

School Nurse Program, the "parental consent form shall te attached 

and forwarded with the referral (Form EPSDT 23). 
  

Reissued January |, 135 ; Page 7 of 19-615 

Replacing June 1, 1979 issue 

 



  

  
  

    

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

The School Nurse Program which required parental consent forms is 

in effect only from September through April. Summer referrals go 

to the local health unit. In the event the local OFS cannot secure 

a signed parental consent form, the school nurse must obtain this 

choi consent through other means. 

As parental consent forms will be distributed prior to clearing with 

the health unit that a child was previously screened, extra care must 
be taken to document the following information: 

(a) The consent form was returned signed or not signed by the 

parent/guardian. 

(b) The parent/guardian indicated that the child had been 

previously/screened. 

(c) The parent/guardian has been contacted to determine whether it 

might be medically necessary to rescreen a child even though he 

was previously screened and periodicity is not due. - If it is 

not medically necessary that the child be screened, this should 

be documented and the child not screened even though the parental 

consent form is signed. 

(d) Each school nurse will provide the local health unit, on a 

weekly basis, with a maximum of twenty (20) names per EPSDT 

School Nurse on whom she is requested clearance as to whether 

The format by which the information should be requested is 

shown below: 

Child's OFS Child's Screened Date Due Eligible Adequately Tested for Being Followed 
Nace I0# 008 Previously for far Inmunized Sickle Cell in Health Unit 

Periodic Dental Clinic 
Screening Rererral 

  

  

  

  

(e) School age children who have failed two scheduled screening 

appointments shall not be rescheduled unless it is obvious 

that the child should be screened, or_screening is requested 
at a later date. 

Each school nurse should document in the child's record that 

he failed to keep scheduled appointments, whether subsequent 

appointments were made and if the child failed to keep these 

appointments. : 

  

Reissued january |. 1983 Page 8 of 19-613 

Replacing June 1, [979 issue 

 



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  J— 

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

Rev. * (f) Procedures to be followed when collecting and shipping blood 
samples to the Office of Health Laboratory for sickle cell 

- testing by electrophoresis, shall be in accordance with the 
contract. - 

(g) School age children in need of dental referrals will be given 
a referral form by the school nurse. Dental referral quatas 
will be sent by the state OFS to each parish school board at 
the beginning of each quarter. A copy of the dental referral 
form should be sent to the local health unit for inclusion in 

} the health unit record and the other copy sent to OFS. 
Rev. 

(h) Each school nurse must notify the Department of Education's 

elementary school age children are screened. The supervisor 
will notify the State OFS and QHSEQ to begin referring the 
next group of school age children (i.e., junior high, elementary) 
to the school nurse. At the time the Department of Education's 

screening the appropriate group of school age children from the 
eligibility lists provided them. 

(i) Education will transfer medical data on those school age chiidren 
Pore screened to the school nurse in the new parish of residence if 

: there is an EPSDT school nurse program in the parish. If there 

is_no program, the record should be retained in the parish of origin. 

(3) The school nurse must confer with the program's physician consul- 
tant as specified in his contract. All contacts with the physician 

_ Rev. * E. Office of Family Security Responsibilities 
  

(1) The State OFS will, at the beginning of the school year, furnish 
the Department of Education with a data processing list identifying 
EPSDT eligibles residing in parishes with EPSDT school nurse programs. 
In addition, daily updates identifying new EPSDT recipients, EPSOT 
recipients whose eligibility has terminated and EPSDT recipients 
who have moved to another parish will be provided to the Department 
of Education. Copies of these lists will be shared with the local 
OFS. 

(2) The local OFS will furnish the school nurse with blank Forms 14-0. 

(3) Requests for screening services shall be raferred to the appropriate 
screening provider, i.2., local health unit or schcol nurse, unless 
otherwise notified by State Office. EPSDT eligible children should 

be referred in the following manner for screening services: 

  

Reissued January I, i383 Page 2 of 19-613 
Replacing June 1, 1879 issua 

 



  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
: Diagnosis and Treatment 

  

(a) Preschool age and elementary school age children should 
be referred to the parish health unit. 

(b) Secondary school age children should be referred to the 
school nurse. Requests received during the summer should 
be referred to the parish health unit. 

The local OFS is responsible for social services follow-up 
*% specifically related to scheduling and transportation. 

Rev. * 

_F. Office of Health Services and Environmental Quality (OHSEQ) Responsibilities 
  

(1) OHSEQ will share, upon obtaining "a release of medical data," with 
the school nurse the following information: 

(a) Whether the child has been screened previously. 

(b) The date the child is due for his periodic screening. 

(c) Whether the child is adequately immunized. 

(da) Whether the child has been tested for sickle cell disease. 

{e) Whether a child is eligible for a dental referral. 

{3 Whether the child is being followed in a health unit clinic. 

2) OHSEQ will perform the periodic screening of those 15-year-olds - 
and older school children who the school nurse states she is unable 

to screen. - 

  

(3) OHSEQ will screen those school age children who request screening 
services during the summer months. 

5) OHSEQ will share with Education any agreements reached with public 
health facilities regarding appointments for diagnosis and treat- 
ment. Education will do the same. 

Rev, * (6) School age children in need of dental referrals will be given a 
referral form by OHSEQ. Dental referral forms will be ordered from 
the fiscal agent by each parish Health Unit at the beginning of each 
quarter. A copy of the dental referral form should be sent to the 
local EPSDT school nurse program for inclusion in the EPSDT Medical 

sd record and other copy sent to OFS. 

  

Reissued January |, 13933 Page 10 of 19-613 
Replacing June 1, 1979 issue 

 



  

Early and Pericdic Screening 
Diagnosis and Treatment 

  

_G. Head Start Responsibilities 
  

(1) Head Start will explain the EPSDT Program to the parents of children 
whom they have determined to be Medicaid eligible. 

(2) Head Start will provide each local health facility and OFS with a 

list of EPSDT eligible children enrolled in the Head Start Programs. 
The list shall contain the following information: 

(a) Child's name 

(b) Date of birth 

Address 

Parents or guardians' name 

Medicaid eligibility number. 

Head Start will refer to the local OFS, the parents of those 
EPSDT/Head Start children whom the health facility has not screened 

previously through the EPSDT Program. The parent in this manner 

may request in person, by telephene or by letter, that the child(ren) 

be scheduled for an initial screening. 

Head Start will provide a signed parental consent form for release 

of data secured by OHSEQ and the New Orleans Cigy Health Department 

during an EPSDT screening. 

Head Start, upon notification by OFS of the child's appointment 
for the initial or periodic screening, will provide tramsportation 

and any other social services which may be required for the child 

to keep the scheduled appointment. 

Head Start, upon notification by the health facility of an appointment 

for diagnosis and treatment, will provide medical transportation and 

any other social services to the EPSDT/Head Start child so that the 

appointment may be kept. 

Head Start will advise the local health facility as to whether 

diagnostic and treatment appointments are kept and if not kept, the 

reasons for their not being kept. 

Head Start will be responsible for follow-up with the parents of 

EPSDT/Head Start children to assure that future medical appointments 

are kept. 

Head Start will provide, at no cost to OFS, screening procedures to 

EPSDT/Head Start eligibles nct required by Louisiana EPSDT screening 

guidelines, but required in the Head Start Performance Guidelines. 

  

Reissued January |, 1933 Page 11 of 15-613 

Replacing June 1, 1979 issue  



      

  

  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
¢ 0 : Diagnosis and Treatment 
  

hE LEA Head Start will obtain a report of the physician's findings and 

recommendation on those children referred by OHSEQ or the New 

Orleans City Health Department for diagnosis and treatment 

services. This report will be shared with OHSEQ, the New Orleans 
City Health Department and OFS. 

_H. Office of Health Services and Environmental Qualities (OHSEQ) and New 

Orleans City Health Department Responsibilities 
  

  

(1) OHSEQ md the New Orleans City Health Department will determine from 

the children have been screened | previously and the date of the last 

. screening. 

(2) OHSEQ and the New Orleans City Health Department will advise Head 

. Start of EPSDT/Head Start eligible children who have been screened 

previously or who have been screened but failed subsequent periodic 

screening appointments. 

(3) OHSEQ and the New Orleans City Health Department will advise OFS 
of those EPSDT/Head Start eligible children who are due for periodic 

screenings. 

(4) Upon presentation of a duly authorized release of medical, social 

iy psychological and educational information form, OHSEQ and the New 
{ Orleans City Health Department will provide a photostatic copy 

(except in EBR Parish) of the EPSDT/Head Start child's screening 
results as noted on the appropriate health form. (In EBR Parish, 

a licensed nurse with the Head Start Program, upon presentation of 

the above mentioned consent form, will be allowed to transfer 
screening results from each child's health record to the Head 

Start records). 

A (5) OHSEQ and the New Orleans City Health Department will schedule for 

'EPSDT/Head Start children needing diagnosis and treatment appointments 

in accordance with existing EPSDT operational procedures. Parents 

will be advised by OHSEQ and New Orleans City Health Department 

that Head Start will assist in providing transportation and other 

services so that a scheduled diagnosis and treatment appointment may 

be kept. 

(6) OHSEQ and New Orleans City Health Department will notify Head Start 

through the use of Form 14-D, of diagnosis and treatment appointments 

scheduled for EPSDT/Head Start eligible children. 

Rev. * 

  

Reissued January |, 1983 Page 12 of 15-613 
Replacing June 1, 1979 issue 

 



  

  

: : : : Early and Periodic Screening 
MEDICAL VENDOR PAYMENTS ; Diagnosis and Treatment 

  

19-614 COVERED SERVICES 
  

A. Screening 
  

Medical screening examinations are conducted by the health units in ; 

each parish including the New Orleans City Health Department and the Department 

of Education in specified parishes. The following are guidelines which 
will be followed by the health units and school boards in the screening 

examinations. 

(1) Screening Components (All Children) 
  

(a) Health and Developmental History 
  

(1) Obtain an adequate physical, mental, and developmental 

history on first visit and update at subsequent visits. 

(ii) Obtain a developmental history to determine if speech, 

the presence of any developmental lags. 

Rev. * The Denver Prescreening Developmental Questionnaire (PDQ) 

will be administered to children during the screening 

visits between 8-12 months of age and at 2, 3, and 5 

years of age. The complete Denver Developmental Screening 

7 . Test will be administered to children who are identified 
Xn! - as having possible developmental lags by the PDQ. The 

! Quay-peterson will be used for latency age children. 

Adolescents will be tested by a state developed 

*% questionnaire. 

(b) Physical Inspection 
  

(1) Check primarily through observation and limited palpation 
at each screening visit for obvious physical defects 

including: orthopedic disorders, hernia, skin disease, 

and genital abnormalities. 

(ii) Heart and lung disorders: 

This may be accomplished through the use of a stethoscope 

and/or through history taking and observation of signs 

and symptoms suggestive of heart and lung disorders. 

  

Reissued January |, 1985 Page 1 of 19-61% 

Replacing July 1, 1977 issue 

 



  

  

wor Early and Periodic Screening MEDICAL VENDO YMENTS 
7 : RM : Diagnosis and Treatment 2 
  

For those nurses who are not tzained to use the 
stethoscope in auscultation of the chest, a child 
shall be referred to a physician for a physical 
examination after a history taking and through ob- 
servation of signs and symptoms suggestive of heart 
and lung disorders and in accordance with the follow- 
ing criteria. This policy will remain in effect un- 
til such time as murses are trained in auscultation 
of the chest, 

Criteria: 

Age 0-2: no history of having had a physician's examination, 
(including suscultation of the chest) within one year. 

Age 2-5: no history of having had a physician's examination, 
including auscultation of the chest, within 1 year. 

Age 5-10: no history of having had a rhysician's examination, 
including auscultation of the chest, within 2 years. 

Age 10-21: no history of having had a physician's examination, 
including auscultation of the chest, within 3 years. 

yt The nurse will, during her history taking interview, deter- 
% : mine those persons in need of a physician's examination. 

She will document the patient's record, the basis on which 
this determination is made, : : : 

A written report of a rhysician's findings will be required 
for children between the ages of birth to two (2) years 
when it is determined, in the history taking interview, 
that auscultation of the chest had been performed within 
the yeer. 

(141) Height and weight will be obtained on all persons at each 
screening visit. Indicate variances from normal. 

  

  

(iv) Head circumference will be measured on all children below 

the age of two years at each screening visit and more often 
if indicated. Indicate variance from normal. 
  

(v) Eye, ear, nose, mouth and throat inspection at each screen- 
ing visit for gbnormalities. 

  

  

(vi) Unclothed physical inspection at each acrsening visit if 
behavior permits. 

  

(vii) Blood pressure and pulse on children three years and over. 
  

  Reissued july 1, 1577 Page 2 of 19-61% 
Replacing August 1, 1976 issue 

 



   
  

Early and Periodic Screening 
MEDICAL VENDOR PAYMENTS : Diagnosis and Treatment 
  

C (c) Determination of Immunization Status 
  

Immunization status will be determined at each screening visit 

and immunization records updated according to Office of Health 

(d) Visual Screening 
  

Screening for visual problems for children from birth to age 
three may be performed through history taking and observation. 

  

Visual screening shall be performed through the use of the 

Snellen Chart, Allen Cards, Titmus Machine or their equivalents, 

. at approximately age 3 years (if testable) and again in the 

screening visit for 5 years, 8 years of age and thereafter, 

in accordance with the periodicity schedule or when indicated. 

  

(e) Hearing Screening 
  

- Screening for hearing problems for children from birth to age 

three will primarily be performed through history taking and 

observation. 

  

Hearing screening shall be performed through the use of the 

audiometer at approximately age 3 years (if testable) and again 

in the screening visit for 5 years, 8 vears of age and 

thereafter, in accordance with the periodicity schedule or 

when indicated. 

  

  

(f) Laboratory Procedures 
  

(1) Anemia Screening 
  

Rev, * Hematocrit or hemoglobin values will be determined during 

the screening visit between 8 to 12 months and the 

screening visit at 2 years of age; however, it will not 

be necessary to perform a test if the screening provider 

has obtained a hematocrit or hemoglobin value within the 

past 2 months and said value was within normal range and 

there is no significant screening finding which indicates 

the need for a redetermination on the day of screening. 

Hematocrit or hemoglobin values will be determined during 

all subsequent screening visits after age 2 and up to age 

21; however, it will not be necessary to periorm a test if 

the screening provider has obtained a hematocrit or 
hemoglobin value within the previous six months and said 

value was within normal range and there is no significant 

screening finding which indicates the need for a redetermina- 

ki tion on the day of screening. 

  

Reissued January |, 1985 Page 3 of 19-6145 
Replacing July 1, 1377 issue 

 



  

  

Early and Periodic Screening 
MEDICAL VENDOR PAYMENTS Diagnosis and Treatment 
  

(! ’ 

a? (11) Sickle Cell Disease and Sickle Cell Trait Screening 
  

(1ii) Urine Screening 
  

Urine screening, to determine as a minimum the presence of 
sugar, -blood and albumin, will be performed at each screening.. 
depending upon the success in obtaining a voided urine 

. specimen. 

  

(iv) Lead Poisoning Screening 
  

Rev. * Screening for lead poisoning will be performed at each 

screening visit for children between 1 and 6 years of age. 

Children age 6 and over shall be screened when indicated. 

(v) PKU and Hypothyroid Screening 
  

PKU and hypothyroid screening tests shall 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. Persons over age one will be 

{ *% screened if indicated. 

(g) Nutritional Status Assessment 
  

Height, weight, head circumference, hemoglobin or hematocrit 

values as well as the other physical and laboratory determinations 

carried out in the screening process shall be used in assessing 

nutritional status. 

  

- (2) Periodicity of Screening 

Eligible persons shall be scheduled for screening services, if not 

under regular medical care, at the following ages: the first 
Rev. * screening may occur at any time during the first month of life; and 

then at 8-12 months of age; 2, 3, and 5 vears of age and everv three 

years thereafter. Every effort should be made to _. 
schedule persons for screening on a timely basis coinciding with the 

periodicity schedule during the first and second screening. The child 

should be scheduled either two weeks before or two weeks following the 

child's birthday at ages 2, 3, and 5 vears of age and every three vears 

*% after. : 

  

  

  

  

Scheduling for rescreening services will be flexible dependent om 

risk factors, individual health needs and person's age upon entrance 

into the Program. 

  
Reissued January |, 1583 Page 4 of 19-614 

Replacing July 1, 1977 issue 

 



  

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening, 

Diagnosis and Treatment 

  

(3) Screening Personnel 
  

Screening shall be performed under the supervision of a physician, 
but the presence of the physician is not required during the 
screening procedure. 

Screening personnel may include public health nurses, school 

nurses, nutritionists, health aides, laboratory technicians, 

social workers, etc., who will be involved in the screening 

process which includes conducting screening interviews, 
physical inspections and necessary tests. 

B. Preventive Health Care, Diagnosis and Treatment 
  

If, as a result of screening, it is suspected or confirmed that an 

individual -has a health or psychological problem, then that individual 

shall be referred to the proper resource for further diagnosis and 
treatment. 

(1) Some health services which shall be considered as diagnosis 
  

and/or treatment are as follows: 
  

(a) 

{ \ 

(b) 

- (ec) 

(d) 

(e) 

(£) 

Tuberculin testing shall be performed on each child only 

if indicated by health history or in keeping with Office 

of Health's screening policies that require the "screening 

by tuberculin tests of individuals who have a high risk of 
tuberculosis’, or who lives in areas of the state which 
are considered as high risk areas by the Office of Health. 

  

Stool Examination for ova, cysts and parasites only if 
indicated by the individual's health history. 
  

Psychological Testing - Individuals shall be referred for 

psychological or mental health evaluation if indicated by 

developmental delays, history of poor school performance, 

poor social adjustment and emotional or behavior problems. 

  

PKU shall be performed if no record exists of the test 

having been done prior to the screening visit. 

Venereal Disease - VDRL and G.C. cultures shall be performed 

on individuals only if indicated. 
  

Physical Examination by Phvsician - if medically indicated. 
  

(2) Diagnosis and Treatment services may be obtained bv referral to 
  

the following sources: 
  

(a) Private Provider 
  

  

Reissued July 1, 1 
Replacing August 1 

  

Page 5 of 19-614 
1976 issue



  
  

   
  

Early and Periodic Screening 
MEDICAL VENDOR PAYMENTS Diagnosis and Treatment 
  

¥ (b) Office of Health Services and Environmental Quality (OHSEQ) 
  

(1) Maternal and Child Health Program 

(ii) Handicapped Children's Program 
(iii) Tuberculosis Control Program 
(iv) Dental Health Program 

(v) Etc. 

(c) New Orleans City Health Department 
  

(i) Tuberculosis Control Program 

(ii) Lead Poisoning Prevention Progr 
(iii) Hearing Program 

. : (iv) Nutrition Counseling Program 

(v) Vision Preservation Program 

(vi) Etec. 

(d) Other State Agencies 
  

(1) Office of Hospitals 
(11) Office of Mental Health 

(iii) Office of Mental Retardation 

(iv) Etec. 

(3) Consultation and Treatment Services 
  

These will include referrals for consultation or treatment services 

not available through OHSEQ, New Orleans City Health Department, 

and Department of Education, e.g., special laboratory services, etc. 

(4) Records and Health Follow-up Services 
  

OHSEQ, New Orleans City Health Department, and Department of 

Education will have the responsibility for keeping health records 

- on the person's progress and for providing medical follow-up 

services. 

(5) Dental Services 
  

All individuals 3 years of age and over shall be referred for dental 

care. Referrals Of children under 3 vears of age may be made on the 

basis of determinations established By physicians and auxiliary 

personnel on the basis of their judgement of need for diagnosis and 

treatment by a dentist. 

  

  

  

Reissved January |, 1983 Page 6 of 13-514 
Replacing July 1, 1977 issue 

 



  

- 

——— i A —— tr SA Wk EE St ott emt em nt a 4 - - . -ie ele 

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening, 

Diagnosis and Treatment 
  

In addition, each participating dentist is required to adhere to 

the following provisions: 

Services will be provided in compliance with Title VI of the Civil - 
Rights Act of 1964, as amended. 

To maintain such records as are necessary to fully disclose the 

extent of the services provided and to furnish the Office of Family 
Security information as it may request from time to time regarding 

claims for payment. : 

Each dentist must agree to accept state payment as payment in 

full for covered services, and to accept no payment in excess of 

the state payment from the patient, insurance company or third 

party. Any payment received will be deducted from the claim before 

it is submitted; or, if received after state payment has been made, 

Health and Human Resources. Under no circumstances must a patient 
eligible for Medicaid be asked or be required to make payment for 

covered services. However, services that are not covered by the 

EPSDT program may be provided at patient's expense. Any amount 
received through error or overpayment will be refunded promptly 

Resqurces. 

Each dentist must insure that all services billed are performed 
by a participating dentist or by dental auxiliaries under the 

supervision of the participating dentist. 

Participant must agree to accept all provisions contained herein. 

Patient Eligibility 
  

" The following conditions must be met in order for a person to 
* be eligible for dental services: 

The person must be under 21 years of age. If otherwise eligible 

a person is eligible for dental services through the month in 

which he reaches his 21st birthday unless his birthdate is on 

the first day of the month. 

authorize the dentist to provide the basic screening package 

or emergency treatment. This form will be forwarded to the 

dentist by way of the referred patient. In order to expedite 

emergency treatment, the referral form may be obtained from the 

health unit after the treatment has been rendered. The Office 

of Family Security, however, will not assume responsibility for 

the patient's eligibility until it has been verified by a referral 

form. 

  

Reissued June 1, 1979 Page 7 of 19-614 

Replacing August 1, 1976 issue 

 



  

  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

Rev.* The referral from the health unit is valid for one year from date 
© kk of issuance. After this time a new referral will have to be made 

for additional treatment. ; 

The person must present his monthly medical eligibility card at 
each visit for the participating dentist to determine his current 
eligibility status and to obtain the correct OFS number. Medical 
eligibility cards are issued monthly and are valid only for that 

month. A person eligible for EPSDT services on any day in any 

given month is eligible for the entire month and the OFS number 

does not change during the month; however, a person may remain 

eligible for services in subsequent months but have a new OFS 
number assigned to him. To insure prompt payment, it is highly 

be entered on each claim. The participating dentist should consider 

the duration of each plan of treatment and plan accordingly, for 

if the treatment plan will require an extended period of time the 
patient may reach 21 years of age or become ineligible for services 

for other reasons. 

Dental Auxiliaries 
  

Dental auxiliary personnel may provide services under the general 

direction of a licensed dentist in such capacities as are specified by 

the Louisiana State Board of Dentistry. The extent to which a dentist 
may use and be reimbursed for services ‘of auxiliaries is limited by 

regulations of the Louisiana State Board of Dentistry. 

Treatment Authorization 
  

All services will require pre-authorization 
  

Rev.* The local parish health unit will (except in Orleans and Jefferson 
- Parishes where the responsibility is shared with the EPSDT School 

*% + Nurses the local Human Development offices, and the Health Unit) 

upon issuance of the EPSDT Dental Billing and Referral Form (EDS 

ment or the basic screening package. 

Except for emergency treatment the dentist will, before proceeding 

for review and subsequent authorization for provision of the addition- 

al needed services. 

  

Reissued June 1, 1979 Page 8 of 15-614 
Replacing August 1, 1976 issue 

 



    
  

  

  

: Early and Periodic Screening, 
. MEDICAL VENDOR PAYMENTS 

Diagnosis and Treatment 
  

Fees 

The usual and customary fee up to a contractual maximum will be 

the method by which payment for services will be made. The dentist 
shall charge his usual and customary fee for the service performed 

In the event that his usual and customary fee exceeds the maximum 
established fee, the dentist will be paid the latter. If the practi- 

tioner's usual and customary fee is less than the maximum established 
fee it must be used. The dentist may be required to demonstrate his 

usual and customary charges by presentation of his records for inspection. 

Program Monitoring 
  

A necessary part of any dental program involving third party payment 

is the provision for monitoring the care provided. 

Random sampling of completed patients will be conducted by the 

Office of Family Security through a review mechanism. 

Participation as a provider of dental services constitutes agree- 

ment with this procedure, and providers agree to make available all 

records and radiographs for any patient being evaluated by said review 

committee. : 

DENTAL SERVICES 
  

: The dental services provided under the EPSDT Dental Program shall 
consist of those basic services essential for the prevention and control 

of dental diseases and maintenance of oral health. “& 

Emergency Services 
  

In those instances in which a patient is appointed on an emergency 

basis and no definitive treatment is rendered, a charge as specified on 

the fee schedule may be made to cover the emergency visit plus a fee 

for necessary X-rays. If on the other hand some definitive treatment 

is rendered, such as restoration, extraction, palliative, etc., a charge 

may be made for the treatment only and not for the emergency visit. 

Emergency dental care services are those necessary to control bleeding, 

relieve pain, eliminate acute infection; operative procedures which are 

required to prevent pulpal death and the imminent loss of teeth; treat- 

ment of injruies to the teeth or supporting structures (e.g., bone or 
soft tissues contiguous to the teeth); and palliative therapy for 
pericoronitis associated with impacted teeth. 

  

Reissued June 1, 1979 : : Page 9 of 19-614 
Replacing August 1, 1976 issue 

 



  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

4 

Rl 2a 
oa om 

These Services are: 

¥ be Disgrostic Services 

Control bleeding 
Relieve pain (extraction of tooth if necessary) 
Eliminate acute infection : 

Intra-oral incision and drainage for abscess 
Extra-oral incision and drainage for abscess 
Open pulp chamber to establish drainage 
Chemoctheravy 

Operative procedures which are required to prevent pulpal death and 
{rminent loss of teeth. (Excavation of decay and placement of 
appropriate palliative filling.) 

Trestment of injuries of the teeth or SuppoTHing structures (e.g. bone 

or soft tissues contiguous to the teeth). ike 

Fracture of the tooth 

Fracture of bone (maxilla or mandible) 
lodgement of foreign body 
Lacerations 

Palliative therapy for pericoronitis associated with impacted teeth. 

Restoration procedures are not considered emergency frosaduves, 

  

Basic Screening Package 

The basic screening package shall consist of examination, prophylaxis, 
topical application of fluoride, bitewing x-rays on all patients and 
anterior periapical x-rays on patients under 8 years of age and 
instruction in oral hygiene. For this basic screening package the 

  

provider will be paid the fee as indicated on the fee schedule, 

Examination: 
  

This service includes the preparation of charts, treatment plan and 

reporting forms. 

Radiographs 
  

Submission of x-rays is not necessary unless the preauthorization 
request contains services from category (B) of the Maximmm Fee Schedule. 
(See Page 18 of 19-614) X-rays when submitted should always be properly 
mounted, dated, and of good diagnostic quality. Requested retakes 
will be provided at no charge. A complete intra-oral series consists 
of films sufficient in number and quality to detect anomalies, diseases, 
and to evaluate develooment. 

  

Issued AUG