Louisiana Medical Assistance Program EPSDT Services Provider Manual

    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. 

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Revised October 9, 1990 

 



   
b. 

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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. 

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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. 

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EPSDT Services Provider Manual Ha 

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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. 

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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. 
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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 

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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. 

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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 : 

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1 

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 

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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. 

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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. 

2-13 

Revised October 9, 1990 

 



  

Louisiana Medical Assistance Program ‘ 

EPSDT Services Provider Manual 

>
.
 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

  

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. 

2-16 

Revised October 9, 1990 

 



  

e. 

Louisiana Medical Assistance Program 

EPSDT Services Provider Manual uk 

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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Louisiana Medical Assistance Program 
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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 

2-18 

Revised October 9, 1990 

 



Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

(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 
Dauicod Nctober 9S. 1990 

: 

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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 

Ravicad Netober 9. 1990  



  

Louisiana Medical Assistance Program 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual : 

) 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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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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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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

- 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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual * 

  

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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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 

Revised DNctcher 9. 1990 

 



  

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); 

2-39 

 



  

Louisiana Medical Assistance Program 

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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Louisiana Medical Assistance Program 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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 

Revised October 9, 1990 Al-2 

 



Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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. 

Revised October 9, 1990  



  

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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Louisiana Medical Assistance Program 
EPSDT Services Provider Manual 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual E 

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. 

Revised October 9, 1990 Al -6 

 



  

Louisiana Medical Assistance Program 

EPSDT Services Provider Manual -.: 

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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Louisiana Medical Assistance Program -.. : ‘ 

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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Louisiana Medical Assistance Program 

EPSDT Services Provider Manual 

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. 

Revised October 9, 1990 Al-9 

 



   
Louisiana Medical Assistance Program 

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. : 

Revised October 9, 1990 Al1-10 

 



  

Louisiana Medical Assistance Program 

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. 

Revised October 9, 1990 Al-11 

 



  

Louisiana Medical Assistance Program : ’ 

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. 

Revised October 9, 1990 Al-12 

 



  

Louisiana Medical Assistance Program 

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. 

Revised October 9, 1990 Al-13 

 



  

Louisiana Medical Assistance Program 
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. : 

Revised October 9, 1990 Al-14 

 



Louisiana Medical Assistance Program 

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 

Revised October 9, 1990 Al-16 

 



  

Louisiana Medical Assistance Program 
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 

Revised October 9, 1990 Al-17 

 



  

Louisiana Medical Assistance Program 
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 

Revised October 9, 1990 . Al-18 

 



  

Louisiana Medical Assistance Program 

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 

Revised October 9, 1990 Al-19 

 



  

Louisiana Medical Assistance Program 
oe 

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 

Revised October 9, 1990 Al-20 

 



  

Louisiana Medical Assistance Program 

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 

Revised October 9, 1990 Al-21 

 



  

Louisiana Medical Assistance Program 

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 

Revised October 9, 1990 Al-22 

 



  

Louisiana Medical Assistance Program 
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 

Revised October 9, 1990 

 



  

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 

Revised October 9, 1990 

 



  

Louisiana Medical Assistance Program 
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 
Revised October 9, 1990 

 



Louisiana Medical Assistance Program 

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
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W
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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 

O
O
O
 
N
O
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H
W
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[ 
J 

[ 
] 

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
T
M
m
M
o
O
o
O
O
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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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o
o
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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 = ~- 

  

  

  

    

  

  

  

  

  

    

   

    

  

   

    
  

  

tee (Peer 

WILLIE TO ARL : ip REMITTANCE ACYIC tk PR ithe : 
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: 01489402 LANG : t 091150 GS1150 19003 FER1GCIC scaeemiy EV A ngRSE ¢CCC ¢Cee. GQ - 4GGO 02€4187100¢0C 

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v CAINS : 
ob i mm— ise -— fC mmm a———g em cme i mm teem + =e= e—— 

uiIEE dn ERVIN © JC GS10SE 0S1G50 eee c6 C0 00 0264187100060 
01 0AREC . 14} i tn oa ET ok ae h 

Yd G0 

CENIED CLAIMS TOMS } 1 cams kel Ra ‘ 
  

  

| 
© Semin cman eumee en owe © cm—   

a mes comm Es ww Se—  ——     
  

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.