HCIC Provider Manual s1
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CHAPTER 4 – COVERED SERVICES
4.4 – EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM The Early and Periodic Screening, Diagnostic and Treatment program (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for members under the age of 21 as described in 42 USC 1396d (a) and (r). EPSDT program services will be provided to Health Choice Integrated Care eligible members who are 18, 19 and 20 years of age in the Integrated RBHA program. The EPSDT program is governed by federal and state regulations and community standards of practice. All PCPs who provide services to Health Choice Integrated Care eligible members age 18-20 are required to provide comprehensive health care, screening and preventive services, including, but not limited to:
• Primary prevention;
• Early intervention;
• Diagnosis; and
• All services required to treat or improve a defect, problem or condition identified in an EPSDT screening.
Note: A well-child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and Dental periodicity schedules.
REQUIREMENTS FOR EPSDT PROVIDERS
PCPs are required to comply with regulatory requirements and Health Choice Integrated Care preventative requirements which include:
• Documenting immunizations into Arizona State Immunization Information System (ASIIS) and enroll every year in the Vaccine for Children Program.
• Providing all screening services according to the AHCCCS Periodicity Schedule and community standards of practice. The Periodicity Schedule can be viewed by accessing the AHCCCS’ website at: http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400pdf
• Using current AHCCCS standardized EPSDT Standards and Tracking Forms to document services provided and compliance with AHCCCS standards.
• Sending copies of EPSDT Tracking forms to Health Choice Integrated Care on a monthly basis.
Health Choice Integrated Care Attn: Maternal Health and EPSDT Coordinator 1300 South Yale Street Flagstaff, AZ 86001 Page 1 of 12 Last Revised: October, 2015
Business Phone: (928) 774-7128 Toll Free: 1-877-923-1400 Business Fax: (855) 408-3400 • Using all clinical encounters to assess the need for EPSDT screening and/or services.
• Documenting in the medical record the member’s decision not to participate in the EPSDT program, if appropriate.
• Referring Health Choice Integrated Care members to Children’s Rehabilitative Services (CRS)when they have conditions covered by the CRS program.
• Making referrals for diagnosis and treatment when necessary and initiate follow-up services within 60 days.
• Reporting all EPSDT encounters on required claim forms, using the Preventive Medicine Codes.
• Initiating and coordinating referrals to behavioral health providers as necessary.
An EPSDT screening includes the following basic elements:
• Comprehensive health and developmental history, including growth and development screening (includes physical, nutritional and behavioral health assessments).
• Comprehensive unclothed physical examination.
• Appropriate immunizations according to age and health history.
• Laboratory tests appropriate to age and risk for the following: dyslipidemia testing, A1C testing, tuberculosis skin testing, anemia testing and sickle cell trait.
• Health education and counseling about development (body image), healthy lifestyles (healthy eating, physical activity, risk reduction (tobacco, alcohol and other drugs) and accident and disease prevention.
• Appropriate dental screening and referral.
• Appropriate vision and hearing/speech testing.
• Obesity screening using the BMI percentile for.
• Anticipatory guidance.
HEALTH EDUCATION
The PCP is responsible for ensuring that health counseling and education are provided at each EPSDT visit. Anticipatory guidance should be provided so that parents or guardians know what to expect in terms of the child's development. In addition, information should be provided regarding accident and disease prevention, and the benefits of a healthy lifestyle.
PERIODIC SCREENINGS
The AHCCCS EPSDT Periodicity Schedule specifies the screening services to be provided at each stage of the member’s development. The AHCCCS EPSDT Periodicity Schedule (Exhibit 430-1) can be viewed at the AHCCCS website, http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400pdf under Policy 430. This schedule follows the Center for Disease Control (CDC) recommendation. Members may receive additional inter-periodic screening at the discretion of the provider. Health Choice Integrated Care does not limit the number of well- visits that members under age 21 receive. Claims should be billed with the following CPT/ICD-9-CM Diagnosis Codes based on age appropriateness:
Codes to Identify Well-Care Visits - Adolescents
CPT Codes ICD-9-CM Diagnosis
99383-99385, 99393-99395 V20.2, V70.0, V70.3 V70.5, V70.6, V70.8, V70.9
Well Visits for sports and other activities should be based on the most recent EPSDT Well Visit, as the annual Well Visits are comprehensive and should include all of the services required for sports or other activities. AHCCCS does not cover sports or other physicals solely for that purpose. If it can be combined with a regularly scheduled EPSDT visit, it is covered, though no additional payment would be allowable for completing the school or other organization paperwork that would allow the member to participate in the activity.
NUTRITIONAL ASSESSMENT & NUTRITIONAL THERAPY
Nutritional assessments are conducted to assist EPSDT members whose health status may improve with nutrition intervention. AHCCCS covers the assessment of nutritional status provided by the member's primary care provider (PCP) as a part of the EPSDT screenings specified in the AHCCCS EPSDT Periodicity Schedule, and on an inter-periodic basis as determined necessary by the member’s PCP. AHCCCS also covers nutritional assessments provided by a registered dietitian when ordered by the member's PCP. This includes EPSDT eligible members who are under or overweight.
Commercial Oral Supplemental Nutritional Feedings provides nourishment and increases caloric intake as a supplement to the member's intake of other foods, or as the sole source of nutrition for the member. Nourishment is taken orally and is generally provided through commercial nutritional supplements available without prescription.
Medical necessity for commercial oral nutritional supplements must be determined on an individual basis by the member’s PCP or attending physician, using at least the following criteria:
• The member is at or below the 10th percentile on the appropriate growth chart for their age and gender for three months or more
• The member has reached a plateau in growth and/or nutritional status for more than six months
Page 3 of 12 Last Revised: October, 2015 (prepubescent)
• The member has already demonstrated a medically significant decline in weight within the past three months (prior to the assessment)
• The member is able to consume/eat no more than 25% of his/her nutritional requirements from appropriate food sources
• Absorption problems as evidenced by emesis, diarrhea, dehydration, and/or weight loss and intolerance to milk or formula products has been ruled out
• The member requires nutritional supplements on a temporary basis due to an emergent condition; i.e. post-hospitalization (PA is not required for the first 30 days), or
• The member is at high risk for regression due to chronic disease or condition and there are no alternatives for adequate nutrition.
The following requirements apply:
• Nutritional therapy requires prior authorization and approval by the Health Choice Integrated Care Medical Director.
• Once prior authorization has been attained, a fully completed EPSDT Exhibit 430-2 Certificate of Medical Necessity for Commercial Oral Nutritional Supplements should be filled out and sent directly to the Durable Medical Equipment provider for handling. The form is available on the AHCCCS website at:
http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf
IMMUNIZATIONS/VACCINES
EPSDT covers all immunizations for members 18, 19 and 20 years of age. Immunizations must be provided according to the AHCCCS Recommended Childhood Immunization Schedules and be up-to- date. Providers are required to coordinate with the Arizona Department of Health Services’ (ADHS) Vaccine for Children Program (VFC) to obtain vaccines for Health Choice Integrated Care members who are 18 years of age.
Additional information can be attained by calling VFC at 602-364-3642, or by accessing their website at http://azdhs.gov/phs/immunization/vaccines-for-children/#vfc .
Arizona law requires the reporting of all immunizations administered to children under 19 years old. Immunizations must be reported at least monthly to ADHS. Reported immunizations are held in a central database, the Arizona State Immunization Information System (ASIIS) that can be accessed online to obtain complete, accurate records.
The human papilloma virus (HPV) vaccine for female and male EPSDT members is covered through 20 years of age. BODY MASS INDEX (BMI)
Providers should calculate each member’s BMI starting at each EPSDT visit. Body mass index is used to assess underweight, overweight, and those at risk for overweight. BMI for adolescent members is gender and age specific. PCPs are required to calculate the member’s BMI and percentile. Additional information is available at the CDC website, www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm.
The following established percentile cutoff points are used to identify underweight and overweight in children:
Body Mass Index (BMI) Table Category BMI-for-age < 5th percentile
At risk of overweight BMI-for-age 85th percentile to < 95th percentile
Overweight BMI-for-age > 95th percentile
If a member is determined to be below the 5th percentile, or above the 85th percentile, the PCP should provide guidance to the member and the member’s parent or guardian regarding diet and exercise for the member. Additional services may be provided or referrals made if medically necessary.
EYE EXAMS AND PRESCRIPTIVE LENSES
EPSDT covers eye examinations according to the AHCCCS EPSDT Periodicity Schedule and as medically necessary using standardized visual tools. Prescriptive lenses are provided to correct or ameliorate defects, physical illness and conditions discovered by EPSDT screenings, subject to medical necessity.
HEARING/SPEECH SCREENING
Hearing evaluation consists of appropriate hearing screens given according to the EPSDT schedule. Evaluation consists of history, risk factors, parental questions and impedance testing.
• Pure-tone testing should be performed when medically necessary.
• Speech screening shall be performed at each EPSDT visit.
DENTAL SCREENING AND REFERRALS
Oral health screenings are to be conducted at every EPSDT visit.
In addition to the screening, members must be referred to a dentist at least annually. Documented dental findings and treatment must be included in the member’s medical record in the PCP’s office.
Page 5 of 12 Last Revised: October, 2015 Depending on the results of the oral health screening, referral to a dentist should be made according to the following timeframes:
• Emergent -(Within 24 hours) Pain, infection, swelling and/or soft tissue ulceration of approximately two weeks duration or longer
• Urgent -(Within three days) Decay without pain, spontaneous bleeding of the gums and/or suspicious white or red tissue areas
• Routine -(Within 45 days of request) none of the above problems identified.
The member or the member’s parent or guardian may also self-refer and schedule dental appointments for the member with any Health Choice Integrated Care contracted general dentist. They may go directly to the dentist without seeing the PCP first and no authorization is required.
COCHLEAR AND OSSEOINTEGRATED IMPLANTATION
Cochlear Implant
Cochlear implantation provides an awareness and identification of sounds and facilitates communication for persons who have profound, sensorineural hearing loss (nerve deafness). Deafness may be prelingual/perilingual or postlingual.
AHCCCS covers medically necessary services for cochlear implantation solely for EPSDT members. Cochlear implantation is limited to one (1) functioning implant per member. AHCCCS will not cover cochlear implantation in instances where individuals have one functioning cochlear implant.
Candidates for cochlear implants must meet criteria for medical necessity, including but not limited to, the following indications:
• A diagnosis of bilateral profound sensorineural deafness (using age-appropriate standard testing), with little or no benefit from a hearing (or vibrotactile) aid, as established by audiologic and medical evaluation;
• Presence of an accessible cochlear lumen structurally suited to implantation, with no lesions in the auditory nerve and acoustic areas of the central nervous system, as demonstrated by CT scan or other appropriate radiologic evaluation;
• No known contraindications to surgery
• Demonstrated age appropriate cognitive ability to use auditory clues, and
• The device must be used in accordance with the FDA approved labeling. Coverage of cochlear implantation includes the following treatment and service components:
• Complete auditory testing and evaluation by an otolaryngologist, speech-language pathologist or audiologist
• Pre-surgery inpatient/outpatient evaluation by a board certified otolaryngologist
• Diagnostic procedures and studies, including CT scan or other appropriate radiologic evaluation, for determining candidacy suitability
• Pre-operative psychosocial assessment/evaluation by psychologist or counselor
• Prosthetic device for implantation (must be non-experimental/non-investigational and be Food and Drug Administration approved and used according to labeling instructions)
• Surgical implantation and related services
• Post-surgical rehabilitation, education, counseling and training
• Equipment maintenance, repair and replacement of the internal/external components or both if not operating effectively and is cost effective.
• Examples include but are not limited to: the device is no longer functional or the used component compromises the member’s safety. Documentation which establishes the need to replace components not operating effectively must be provided at the time prior authorization is sought.
• Cochlear implantation requires PA from the Health Choice Integrated Care Medical Director.
Osseointegrated implants (bone anchored hearing aid [BAHA])
AHCCCS coverage of medically necessary services for osseointegrated implantation is limited to EPSDT members. Osseointegrated implants are devices implanted in the skull that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer. These devices are indicated only when hearing aids are medically inappropriate or cannot be utilized due to congenital malformation, chronic disease, severe sensorineural hearing loss or surgery. Osseointegrated implantation requires PA from the Health Choice Integrated Care Medical Director.
ORGAN AND TISSUE TRANSPLANTATION SERVICES
EPSDT covers all non-experimental transplants necessary to correct or ameliorate defects, illnesses and physical conditions whether or not the particular non-experimental transplant is covered by the AHCCCS State Plan.
Page 7 of 12 Last Revised: October, 2015 CONSCIOUS SEDATION
AHCCCS covers conscious sedation for members receiving EPSDT services. Conscious sedation provides a state of consciousness that allows the member to tolerate an unpleasant procedure while continuously maintaining adequate cardiovascular and respiratory function, as well as the ability to respond purposely to verbal command and/or tactile stimulation.
Coverage is limited to the following procedures except as specified below:
• Bone marrow biopsy with needle or trocar
• Bone marrow aspiration
• Intravenous chemotherapy administration, push technique
• Chemotherapy administration into central nervous system by spinal puncture
• Diagnostic lumbar spinal puncture, and
• Therapeutic spinal puncture for drainage of cerebrospinal fluid.
Additional applications of conscious sedation for members receiving EPSDT services will be considered on a case by case basis and require medical review and prior authorization by the Health Choice Integrated Care Medical Director for enrolled members. BEHAVIORAL HEALTH SERVICES
AHCCCS covers medically necessary behavioral health services for Health Choice Integrated Care members eligible for EPSDT services. EPSDT behavioral health services include the services listed in Federal Law 42 USC 1396d (a) necessary to correct or ameliorate mental illnesses and conditions discovered by the screening services whether or not the services are covered under the AHCCCS Plan.
Health Choice Integrated Care providers are responsible participation in the coordination of physical health and behavioral services covered under the scope of the member's enrolement with Health Choice Integrated Care as the Integrated RBHA. Health Choice Integrated Care further ensures services are provided in accordance with AHCCCS/ADHS EPSDT and Dental Periodicity Schedules and PCP's compliance with all EPSDT standards and contract requirements of the EPSDT program including delivery of comprehensive periodic health and developmental screenings that are all-inclusive visits performed by a contracted Health Choice Integrated Care practitioner.
Health Choice Integrated Care contracted PCPs, within the scope of their practice, who wish to provide psychotropic medications and medication adjustment and monitoring services may do so for members diagnosed with Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder, depressive (including postnatal depression) and/or anxiety disorders. The ADHS/DBHS Bureau of Quality and Integration (BQ & I) Specifications Manual provides clinical guidelines, including assessment tools and algorithms for each of the three named diagnoses. The clinical guidelines are to be used by the PCPs as an aid in treatment decisions.
RELIGIOUS NON-MEDICAL HEALTH CARE INSTITUTION SERVICES
AHCCCS covers medically necessary services provided in religious nonmedical health care institutions or nursing facilities for EPSDT members who need nursing care 24 hours a day, but do not require hospital care under the daily direction of a physician. The religious non-medical health care institutions are exempt from licensure or certification requirements.
CASE MANAGEMENT SERVICES
AHCCCS covers case management services as appropriate for Health Choice Integrated Care members eligible for EPSDT services. In EPSDT, case management involves identifying the health needs of a member, ensuring necessary referrals are made, maintaining health history, and initiating further evaluation/diagnosis and treatment when necessary.
CHIROPRACTIC SERVICES
AHCCCS covers chiropractic services to Health Choice Integrated Care members eligible for EPSDT services when ordered by the member’s PCP and approved by Health Choice Integrated Care in order to ameliorate the member’s medical condition.
PERSONAL CARE SERVICES
AHCCCS covers personal care services, as appropriate, for Health Choice Integrated Care members eligible for EPSDT services. Page 9 of 12 Last Revised: October, 2015 INCONTINENCE BRIEFS
Incontinence briefs, including pull-ups, are covered in order to prevent skin breakdown and to enable participation in social, community, therapeutic and educational activities under the following circumstances:
• The member is 18, 19 or under 20 years old
• The member is incontinent due to a documented disability that causes incontinence of bowel and/or bladder
• The PCP or attending physician has issued a prescription ordering the incontinence briefs
• Incontinence briefs do not exceed 240 briefs per month unless the prescribing physician presents evidence of medical necessity for more than 240 briefs per month for a member diagnosed with chronic diarrhea or spastic bladder
• The member obtains incontinence briefs from providers in Health Choice Integrated Care’s network
• Prior authorization has been obtained as required by Health Choice Integrated Care.
MEDICALLY NECESSARY THERAPIES
AHCCCS covers medically necessary therapies including physical therapy, occupational therapy and speech therapy necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. Therapies are covered under both an inpatient and outpatient basis when medically necessary.
TUBERCULIN SKIN TESTING
Tuberculin skin testing should be performed as appropriate to age and risk. Members at increased risk of tuberculosis (TB) include those who have contact with persons:
• Confirmed or suspected of TB;
• In jail during the last five years;
• Living in a household with an HIV-infected person or the child is infected with HIV; and
• Traveling/emigrating from, or having significant contact with persons indigenous to, endemic countries.
State Programs
CHILDREN’S REHABILITATIVE SERVICES (CRS) Effective October 1, 2013 AHCCCS enrolled children with CRS-qualifying conditions under the Acute line of business were transitioned to United Health Care Community Plan for not only CRS related conditions but for all medical care. http://www.uhccommunityplan.com/
AHCCCS OFFICE OF SPECIAL PROGRAMS
Children who have been diagnosed with the following genetic metabolic conditions and who need medical foods may receive services directly through the AHCCCS Office of Special Programs. AHCCCS covers medical foods, within the limitations specified in the AHCCCS Medical Policy Manual (AMPM), Chapter 320-H, titled Medical Foods, for any member diagnosed with one of the following inherited metabolic conditions:
• Phenylketonuria
• Homocystinuria
• Maple Syrup Urine Disease
• Galactosemia (requires soy formula)
• Beta Keto-Thiolase Deficiency
• Citrullinemia
• Glutaric Acidemia Type I
• Methylcrotonyl CoA Carboxylase Deficiency
• Isovaleric Acidemia
• Methylmalonic Acidemia
• Propionic Acidemia
• Arginosuccinic Acidemia
• Tyrosinemia Type I
• HMG CoA Lyase Deficiency
• Cobalamin A, B, C Deficiencies
Metabolic Disorder Medical Foods – Coverage Entity:
• Members receiving EPSDT and KidsCare services that have been diagnosed with a metabolic disorder included in the AMPM, Chapter 320-H, Medical Foods, are eligible for services through CRS. Page 11 of 12 Last Revised: October, 2015 • Members receiving EPSDT services and KidsCare members must receive metabolic formula through CRS.
• Members receiving EPSDT services and KidsCare members who require modified low protein foods receive them through AHCCCS Administration.
• AHCCCS Administration is responsible for providing both necessary metabolic formula and modified low protein foods for members 21 years of age and older who have been diagnosed with one of the inherited metabolic disorders included in the AMPM, Chapter 320-H, Medical Foods section.
• Health Choice Integrated Care is responsible for initial and follow-up consultations by a genetics physician and/or a metabolic nutritionist, lab tests and other services related to the provision of medical foods for enrolled members diagnosed with a metabolic disorder included in the AMPM, Chapter 320–H, Medical Foods section.
Further information can be obtained by contacting the Office of Special Programs at 602-417-4053 or by referring to the AHCCCS Medical Policy Manual and referring to Chapter 320-H, Medical Foods.