130 CMR, § 450.143

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Current through Register 1536, December 6, 2024

Section 450.143 - EPSDT Services: Description of Medical Protocol and Periodicity Schedule Visits (EPSDT Visits)

(A)Initial EPSDT Visit.

(1) An initial EPSDT visit must be provided for every

(a) new member;

(b) member previously seen only for sick care; and

(c) newborn previously seen only in the hospital.

(2) An initial EPSDT visit includes the recording of

(a) family, medical, behavioral health, developmental, and immunization history;

(b) a review of all systems;

(c) a comprehensive physical examination; and

(d) all exams, assessments, screening, and laboratory work indicated on the Medical Schedule as appropriate for the member's age.

(B)EPSDT Periodic Visit.

(1) An EPSDT periodic visit consists of all exams, assessments, screenings, and laboratory work indicated on the Medical Schedule as appropriate for the member's age.

(2) A provider may claim payment for an EPSDT periodic visit only when all the screening procedures on the Medical Schedule that correspond to the member's age have been delivered to the member.

(a) While the screening procedures are based upon a presumption of regular contact with health-care providers, many members will need additional screening procedures to bring them up-to-date.

(b) It is the provider's responsibility to provide those additional screening procedures necessary to bring the member up-to-date with his or her preventive health care according to the Medical Schedule.

(3) If the provider is unequipped to perform a test (for example, if he or she does not have an audiometer and an audiometric test is required), the provider must make a screening referral to another provider. However, in every case, for the referring provider to claim payment for an EPSDT periodic visit

(a) all required screening procedures must be performed; and

(b) the referring provider must receive and document all results in the member's medical record.

(C)EPSDT Interperiodic Visit. An EPSDT interperiodic visit is any visit not indicated on the Medical Schedule. Such visits may be either

(1) preventive health-care visits provided at an age or age interval not indicated on the Medical Schedule; or

(2) a screening that is medically necessary to determine the existence of a suspected illness or condition, or a change in or complication of a preexisting condition.