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June 03, 2022, 01:53 EDT

Chapter : EPSDT Supplement B

Updated: 5/19/2022

GENERAL INFORMATION ON EPSDT SERVICES

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a Federal law (42 CFR § 441.50 et seq) that requires state Medicaid programs to assure that health problems for individuals under the age of 21 are diagnosed and treated as early as possible, before the problem worsens and treatment becomes more complex and costly. EPSDT is a Medicaid benefit and therefore there are no special enrollment procedures for members to access EPSDT services.

 

EPSDT requires a broad range of outreach, coordination and health services that are distinct from general state Medicaid requirements. EPSDT provides examination and treatment services at no cost to the enrollee.

 

DMAS, its contracted MCOs and their providers have the responsibility to provide EPSDT diagnostic and treatment services according to the DMAS periodicity schedule to all Medicaid/FAMIS fee-for-service/FAMIS Plus enrollees under age 21.  The full scope of EPSDT treatment is available to all children in Medicaid/FAMIS Plus regardless of their chosen MCO. Individuals aged 19 or 20 who are covered under Medicaid expansion are eligible for EPSDT.

 

FAMIS

Children enrolled in the FAMIS Program are not eligible for all EPSDT treatment services.  Children who are eligible for the FAMIS program must enroll with a Managed Care Organization (MCO) in most parts of the state.  Although FAMIS enrollees receive well child visits, they are not eligible for the full EPSDT treatment benefit. 

 

The EPSDT diagnostic and treatment benefit is available to FAMIS Fee-for-Service enrollees.

 

EPSDT Goals

The goals of EPSDT are to identify health concerns, assure that treatment is provided before problems become complex, and to medically justify that services are provided to treat or correct identified problems.

EPSDT requires a broad range of outreach, coordination and health services that are distinct from general state Medicaid requirements, and is composed of two parts:

  • EPSDT periodic screenings or well child check-ups – checkup that should occur at regular intervals.
  • EPSDT/Inter-periodic Screenings, sick visits – unscheduled check-up or problem focused assessment that can happen at any time because of illness or a change in condition.

EPSDT also covers other services, products, or procedures for children, if those items are determined to be medically necessary to “correct or ameliorate” (make better) a defect, physical or mental illness, or condition (health problem) identified through routine medical screening or examination, regardless of whether coverage for the same service or support is an optional or limited service under the state plan.

 

All treatment services require service authorization (before the service is rendered by the provider).

 

The required EPSDT services under Section 1905(r) of the Social Security Act are described below.

Screening Services

Required EPSDT screening components include: 

  • A comprehensive health and developmental history (including assessment of both physical and mental health development);
  • A comprehensive unclothed physical exam;
  • Vision screening by a standardized testing method according to the DMAS periodicity schedule;
  • Hearing screening by a standardized testing method according to the DMAS periodicity schedule;
  • Developmental screening with a standard screening tool according to the American Academy of Pediatrics guidelines;                                     
  • Age appropriate immunizations as needed according to the Advisory Committee on Immunization Practices (ACIP) guidelines;
  • Laboratory tests (including lead blood testing at 12 and 24 months or for a new patient with unknown history up to 72 months or as appropriate for age and risk factors);
  • Health Education/Anticipatory Guidance/problem-focused guidance and counseling.

 

The chart below indicates when a child should receive an EPSDT screening:

 

INFANCY

EARLY CHILDHOOD

LATE CHILDHOOD

ADOLESCENCE

3-5 days

1 month

2 months

4 months

6 months

9 months

 

12 months

15 months

18 months

2 years

30 months

3 years

4 years

5 years

6 years

7 years

8 years

9 years

10 years

 

 

11 years

12 years

13 years

14 years

15 years

16 years

17 years

18 years

19 years

20 years

 

The “EPSDT Screening Services” section located within this chapter provides detailed EPSDT screening information.

Other Necessary Health Care, Diagnostic Services and Treatment Services – Specialized Services

As with all Medicaid services, any limitation that the state imposes on EPSDT services must be reasonable and the benefit provided must be sufficient to achieve its purpose.  In addition, the state must provide other necessary health care, diagnostic services, treatment and other measures listed in the Federal Medicaid statute, to correct and ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not they are covered in the state Medicaid plan. The non-state plan services are called Specialized Services.

The state may determine the medical necessity of the service and subject the service to service authorization for purposes of utilization review.

In addition to the traditional review for medical necessity, Medicaid children who are denied services that do not meet the  general coverage criteria must receive a secondary review to ensure that the EPSDT provision has been considered.  The DMAS, service authorization contractor, and MCO secondary review process for medical necessity must consider the EPSDT correct or ameliorate criteria. The Department must approve the MCO’s second review process for EPSDT prior to implementation or when requested.  Denial for services to children cannot be given until this secondary review has been completed.

No service provided to a child under EPSDT can be denied as “non-covered”, “out-of-network” and/or “experimental” unless the approved secondary review applying EPSDT criteria has been completed and determined that it is not medically necessary.

Outreach and Informing

Federal EPSDT regulations provide that all eligible Medicaid/FAMIS fee for service/FAMIS Plus members under age 21 and their families be informed of the nature and availability of EPSDT services and how to access them.  Informing is accomplished through a number of outreach activities including face-to-face discussions, telephone conversations, and written communications.  The purpose of outreach is to increase EPSDT screening participation.

Outreach and informing is the joint responsibility of DMAS, the Department of Social Services (DSS), participating MCOs, primary care physicians (PCPs) and EPSDT screening providers.

DSS provides the following information about EPSDT services to Medicaid applicants during the initial eligibility interview including the following:

  • Informs families of the benefits of regular preventive health care for their children;
  • Informs families on the range of services available, and how to obtain these services;
  • Informs families that the services are provided at no cost to them; and;
  • Informs families on the available necessary transportation and appointment scheduling assistance. 

The Managed Care Help Line staff informs members of EPSDT services and encourages them to contact their primary care physician or a Medicaid enrolled EPSDT provider as soon as possible to schedule screening appointments for their children. DMAS also sends periodic mailings based on the member’s date of birth to all Medicaid/FAMIS fee-for-service/FAMIS Plus enrolled families to encourage their participation in EPSDT.

MCO informing and outreach responsibilities must include, at a minimum, promotion of EPSDT for new enrollees, including urging them to contact their primary care provider to schedule an initial screening, a clear description of EPSDT services in the member handbook and ongoing member education services encouraging participation in these services. 

definitions

Activities of Daily Living (ADLs):  Activities usually performed in the course of a normal day in an individual's life; and may include eating, dressing, bathing and personal hygiene, mobility including transfer and positioning, bowel and bladder assistance.

Administrative Dismissal:

  1. A DMAS provider appeal dismissal that requires only the issuance of an informal appeal decision with appeal rights but does not require the submission of a case summary or any further informal appeal proceedings; or 
  2. The dismissal of a member appeal on various grounds, such as lack of a signed authorized representative form or the lack of a final adverse action from the MCO or other DMAS Contractor.

Adverse Action: The termination, suspension, or reduction in covered benefits or the denial, in whole or in part, of payment for a service.

Adverse Benefit Determination: Pursuant to 42 C.F. R. § 438.400, means, in the case of an MCO, any of the following:  (i) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv) The failure to provide services in a timely manner, as defined by the State; (v) the failure of an MCO to act within the timeframes provided in §438.408(b)(1) and (2) regarding the standard resolution of grievances an appeals; (vi) for a resident of a rural area with only one MCO, the denial of a member’s request to exercise his or her right, under §438.52(b)(2)(ii), to obtain services outside the network; (vii) the denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.

Appeals:

 

  1. A member appeal is:
    1. For members enrolled in an MCO, in accordance with 42 C.F.R. § 438.400, defined as a request for review of an MCO’s internal appeal decision to uphold the MCO’s adverse benefit determination.  For members, an appeal may only be requested after exhaustion of the MCO’s one-step internal appeal process. Member appeals to DMAS will be conducted in accordance with regulations at 42 C.F.R.§§ 431 Subpart E and 12 VAC 30-110-10 through 12 VAC 30-110-370; or
    2. For members receiving FFS services, defined as a request for review of a DMAS adverse action or DMAS Contractor’s decision to uphold the Contractor’s adverse action.  If an internal appeal is required by the DMAS Contractor, an appeal to DMAS may only be requested after the Contractor’s internal appeal process is exhausted.  Member appeals to DMAS will be conducted in accordance with regulations at 42 C.F.R.§§ 431 Subpart E and 12 VAC 30-110-10 through 12 VAC 30-110-370; or
  2. For services that have already been rendered, a  provider appeal is:
    1.  A request made by an MCO’s provider (in-network or out-of-network) to review the MCO’s reconsideration decision in accordance with the statutes and regulations governing the Virginia Medicaid appeal process.  After a provider exhausts the MCO’s reconsideration process, Virginia Medicaid affords the provider the right to two administrative levels of appeal (informal appeal and formal appeal) in accordance with the Virginia Administrative Process Act at Code of Virginia § 2.2-4000 et seq. and Virginia Medicaid’s provider appeal regulations at 12 VAC 30-20-500 et seq.; or
    2.  For FFS services, a request made by a provider to review DMAS’ adverse action or the DMAS Contractor’s reconsideration decision in accordance with the statutes and regulations governing the Virginia Medicaid appeal process.  If an adverse action requires reconsideration before appealing to DMAS, the provider must exhaust the Contractor’s reconsideration process, after which Virginia Medicaid affords the provider the right to two administrative levels of appeal (informal appeal and formal appeal) in accordance with the Virginia Administrative Process Act at Code of Virginia § 2.2-4000 et seq. and Virginia Medicaid’s provider appeal regulations at 12 VAC 30-20-500 et seq.

Centers for Medicare & Medicaid Services (CMS):  The federal agency that administers the Medicare, Medicaid and State Child Health Insurance programs.

DMAS: The Virginia Department of Medical Assistance Services (DMAS) is the state Medicaid agency that is responsible for administering the EPSDT benefit.

EPSDT (Early and Periodic Screening, Diagnostic and Treatment):  a Federal law (42 CFR § 441.50 et seq) that requires state Medicaid programs to assure that health problems for individuals under the age of 21 are diagnosed and treated as early as possible, before the problem worsens and treatment becomes more complex and costly. 

EPSDT requires a broad range of outreach, coordination and health services that are distinct from general state Medicaid requirements, EPSDT provides examination and treatment services at no cost to the enrollee.

EPSDT Screener:  DMAS enrolled or contracted Medicaid MCO enrolled Physician, Physician’s Assistant, or Nurse Practitioner.

EPSDT Screening:  EPSDT screening services contain the following five (5) elements:

  • A comprehensive health and developmental history, including assessment of both physical and mental health and development;
  • A comprehensive unclothed physical examination;
  • Appropriate immunizations according to the ACIP (Advisory Committee on Immunization Practice) schedule;
  • Laboratory tests (including blood level assessment);
  • Each encounter must be appropriate for age and risk factors, and health education, including anticipatory guidance.

 

FAMIS:  Virginia's program that helps families provide health insurance to their children. FAMIS stands for Family Access to Medical Insurance Security Plan. FAMIS is a separate federal program from Medicaid.  In Virginia, FAMIS enrollees are not eligible for some types of EPSDT specialized services when enrolled in a managed care organization.

FAMIS Plus:  FAMIS Plus is the name given to the Virginia Medicaid program.

Fee for Service and Managed Care:  DMAS provides Medicaid to individuals through two programs: a program utilizing contracted managed care organizations (MCO) and fee-for-service (FFS), which is the standard Medicaid program that uses the DMAS provider network to deliver healthcare services.  “FAMIS fee for service” enrollees are eligible for EPSDT benefits when there is no Managed Care Organization that is contracted to serve their geographic region.

Internal Appeal: A request to the MCO or other DMAS Contractor by a member, a member’s authorized representative or provider, acting on behalf of the member and with the member’s written consent, for review of the MCO’s adverse benefit determination or DMAS Contractor’s adverse action.  The internal appeal is the only level of appeal with the MCO or other DMAS Contractor and must be exhausted by a member or deemed exhausted according to 42 C.F.R. § 438.408(c)(3) before the member may initiate a State fair hearing.

Service Authorization (SA):  The process of determining whether or not the service request meets all criterion for that service and gives authority to providers to allow reimbursement for services. Providers and individuals are notified of each SA decision with a system-generated notice.  SA for specialized inpatient services for FFS enrollees is obtained at DMAS.  SA for Managed Care enrollees must be obtained through the MCO.

State Fair Hearing: The Department’s evidentiary hearing process for member appeals.  Any internal appeal decision rendered by the MCO or DMAS Contractor may be appealed by the member to the Department’s Appeals Division. The Department conducts evidentiary hearings in accordance with regulations at 42 C.F.R.§§ 431 Subpart E and 12 VAC 30-110-10 through 12 VAC 30-110-370.

State Plan for Medical Assistance: The set of benefits approved by the Commonwealth of Virginia and the Centers for Medicaid and Medicare Services.

Third Party Liability (TPL):  Insurance other than Medicaid that is owned by the individual or purchased on the individual’s behalf.  This insurance may be liable for coverage of the requested Medicaid service.  TPL must be billed for services prior to billing Medicaid.

EPSDT SCREENING SERVICES

Qualified EPSDT Screening Providers

Qualified providers of EPSDT screening services include:

  • A physician licensed by the Board of Medicine;
  • A physician assistant licensed by the Board of Medicine under supervision as required by their license;
  • A nurse practitioner licensed by the Boards of Medicine and Nursing and acting within the scope of practice;
  • Federally Qualified Health Centers (FQHCs);
  • Rural Health Clinics (RHCs);
  • Local health departments;
  • School based health clinics; and
  • Other DMAS approved clinics

 

EPSDT providers must be Medicaid enrolled providers and must meet all applicable Medicaid provider and specific EPSDT screening requirements. There are no additional enrollment requirements for qualified providers to participate in EPSDT.

The Primary Care Physician’s Role in Screening

PCPs for children in MCOs must directly provide EPSDT services for all children assigned to them.  Those children who are not enrolled in managed care may obtain these services from any Medicaid enrolled physician or clinic qualified to provide EPSDT services and also offers these services. These qualified Medicaid enrolled fee-for-service EPSDT providers must follow the same requirements indicated in this manual.  The Managed Care Help Line maintains a list of these providers. EPSDT is a Medicaid benefit and therefore there are no special enrollment procedures for members to access EPSDT services.

The PCP or EPSDT screening provider (both MCO and FFS), must perform the following activities related to screening services:

 

  • Advise families of the importance of regular preventive health care for their children and explain EPSDT services.
  • Provide or arrange for initial and periodic EPSDT preventive health screenings according to the DMAS periodicity schedule and screening requirements.
  • Assure that the initial screening is scheduled within thirty (30) days of notification of managed care assignment and immediately upon notification of newly assigned newborns unless the services are declined.
  • Notify families when the next screening is due including those families who have previously declined screening services and encourage them to keep all screening appointments.
  • Schedule the next screening appointment and maintain periodicity and tracking system on screenings.
  • Follow up on missed or incomplete screenings including contacting families and rescheduling the screenings promptly.
  • Coordinate care for children referred to other qualified providers for screening services and specialty care and obtain results of the screenings and other health care services.
  • Maintain a comprehensive and integrated medical record of all health care the child receives including complete documentation of all EPSDT screening components and immunizations given.

 

MCOs may assume responsibility for some of the informing, tracking and notifying functions of PCPs. One of the primary goals of DMAS’ managed care programs is to promote a “medical home” for children so that members under the age of 21 receive both sick and well care from their PCP rather than seek episodic care from an emergency room.  A PCP who chooses not to directly provide screening services must enter into a formal written agreement with a local health department, FQHC, or other qualified EPSDT provider to provide screening services to children in his panel. The referral duration will be at the discretion of the provider, and must be fully documented in the patient's medical record. “Exhibits” at the end of this chapter contains an optional referral form for this purpose. Regardless of the screening arrangements, the PCP must continue to be responsible for the informing, tracking, follow-up and documentation requirements of EPSDT.

The EPSDT Screening Periodicity Schedule

EPSDT screenings are Medicaid’s well child visits and should occur according to the “American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care”. The DMAS periodicity schedule is included as Appendix 1 under “Exhibits” at the end of this chapter.    Providers must obtain a medical history that is inclusive of mental health risk factors and documents the family’s history of mental health conditions. 

EPSDT screenings, inter-periodic screenings and the required components of the screenings do not require service authorization requirements.  However, screenings not performed by the child’s PCP may require a referral from the PCP.  Children not enrolled in managed care are not subject to this referral requirement.

EPSDT Screening Components

This Section describes the required components of EPSDT screenings for members enrolled in Fee for Service and Managed Care Organizations.  The EPSDT comprehensive health screening/well child visit content should be in line with the most current recommendations of the “American Academy of Pediatrics (AAP), Guidelines for Health Supervision”.  Another resource for preventive health guidelines is the AAP compatible “Bright Futures: Guidelines for Health Supervision of Infants, Children, and AdolescentsAll components of EPSDT screenings, including specimen collection, must be provided during the same screening visit.

The following is a description of each of the required age appropriate screening components:

Comprehensive Health and Developmental/Behavioral History

At the initial screening, the screening provider must obtain a comprehensive health, developmental/behavioral, mental health and nutritional history from the child’s parents or a responsible adult familiar with the child, or directly from an adolescent, when appropriate.  This history should be gathered through an interview or questionnaire.  A comprehensive initial history includes a review of the:

  • Family medical history (health of parents and current family members, identification of family members with chronic, communicable or hereditary diseases);
  • Patient medical history (prenatal problems, neonatal problems, developmental milestones, serious illnesses, surgeries, hospitalizations, allergies and current health problems and medications);
  • Nutritional history;
  • Immunization history;
  • Environmental risk (living conditions, water supply, lead, sewage, pets, smokers in home);
  • Family background of emotional problems, problems with drinking or drugs or history of violence or abuse; and
  • Patient History of behavioral and/or emotional problems (educational environment and performance, family and social relationships, hobbies, sports).

In addition, for all adolescent children, the initial history must include:

  • History of sexual activity, if appropriate
  • Menstrual history for females
  • Obstetrical history, if appropriate

 

The history must be updated at each subsequent screening visit to allow serial evaluation.

Developmental Surveillance, Assessment, and Screening

Developmental surveillance should be conducted at each well-child visit. Developmental surveillance is the process of recognizing children who may be at risk of developmental delays.  Surveillance is longitudinal, continuous, and cumulative and is comprised of the following components: parental concerns; developmental history; observation of the child; identification of risk and protective factors; and accurately documenting the process and findings. The following are examples of conducting surveillance:

  • Parental concerns: Simple questions to parents such as “do you have any concerns about your child’s development? Behavior? Learning?  Asking about behavior can help identify issues, as parents may not be able to differentiate between development and behavior.
  • Developmental history: Ask parents about changes since the last visit, and questions about age-specific developmental milestones such as walking, pointing, etc.
  • Observation: The health care provider can often see evidence of age-specific developmental milestones, and may be able to confirm parental concerns. It is also important to monitor the parent’s response to the infant, and vice versa.
  • Risk and protective factors:  Infants born prematurely, at low or very low birth weight, or with prenatal exposure to alcohol, drugs, or other toxins are at risk for developmental delay.  Protective factors to support infants at risk, such as participation in home visitation program, or strong connections within a loving and supportive family, should also be considered in determining the overall degree of risk.

 

Surveillance services are always a subjective observation by the practitioner. Reimbursement for well child visits includes surveillance activities because developmental, hearing and vision surveillance occurs during the course of each EPSDT visit.  When a child has an issue that warrants further investigation by the practitioner, then the child may receive a screening to document the need for further assessment or evaluation. 

DEVELOPMENTAL SCREENING TOOLS

If at any time developmental surveillance demonstrates a risk for developmental delay, a standardized screening tool should be administered to further assess the child. As recommended by the AAP, developmental screening using a standardized screening tool should occur at 9, 18, 24 and 30 months of age or at any time when surveillance indicates a risk for developmental delay. An autism specific screening is recommended at the 18 and 24 month visit. Children should be screened for developmental concerns at least 5 times while they are younger than three years of age.

Developmental assessment and screening differs from surveillance because the activity of assessment and screening includes the use of a standardized developmental screening tool. The tools used may vary according to the type of screening or assessment that is provided.  All of the examples listed below can be performed by a parent or other office staff and interpreted by the physician during the “face to face” portion of the child’s visit. These tools are designed to be used easily as part of the typical office work flow and the tools are very sensitive and specific with proven statistical validity.  

Recommended Developmental Screening Tools

Parents' Evaluation of Developmental Status (PEDS),

Parent-report instrument used to identify general developmental delay in the general primary care population

Ages and Stages Questionnaire (ASQ),

Parent-report instrument used to identify general developmental delay in the general primary care population and/or broad high-risk population

Bayley Infant Neurodevelopmental Screen (BINS),

Practitioner-administered instrument used to identify general developmental delay in the high-risk population

Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale Expressive and Receptive Language Scale (CAT/CLAMS),

Practitioner-administered instrument used to identify general developmental delay in the high-risk population

Language Development Survey (LDS),

Parent-report instrument used to identify language delay in the general primary care population

Clinical Linguistic Auditory Milestone Scale Expressive and Receptive Language Scale (CLAMS),

Practitioner-administered instrument used to identify language delay in the high-risk population

Modified Checklist for Autism in Toddlers

(M-CHAT)

Parent-administered instrument used to screen for autism and developmental delay in the general primary care population

 

Recommended Tools for Focused Screening for Suspected Health Conditions:

Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale Expressive and Receptive Language Scale (CAT/CLAMS),

Practitioner-administered instrument used to identify general developmental delay in the high-risk population

Language Development Survey (LDS),

A parent-report instrument used to identify language delay in the general primary care population

Clinical Linguistic Auditory Milestone Scale Expressive and Receptive Language Scale (CLAMS),

Practitioner-administered instrument used to identify language delay in the high-risk population

Modified Checklist for Autism in Toddlers

(M-CHAT)

Parent-administered instrument used to screen for autism and developmental delay in the general primary care population

Hearing and Vision Screening and Surveillance

Subjective

The subjective screening for hearing and vision is part of the comprehensive history and physical examination. Children’s hearing is assessed according to the AAP policy for “Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening”. Children’s vision assessment should be provided according to the AAP policy for “Eye Examination in Infants, Children, and Young Adults by Pediatricians”. Hearing and Vision screenings follow the most current AAP periodicity schedule as stated in the AAP “Recommendations for Preventive Pediatric Health Care”.

The Virginia Early Hearing Detection and Intervention (EHDI) program, the AAP, and the American Speech-Language-Hearing Association provide information on objective hearing screening methods for infants and toddlers.

The EHDI program has a resource, Protocols for Medical Management, that defines best practices for caring for infants and young children who are in need of follow-up from universal newborn hearing screening programs and for children who are found to have hearing loss. The Early Hearing Detection and Intervention protocols can be accessed the Virginia EHDI Program Web site, http://www.vahealth.org/hearing/. Early and consistent intervention specific to hearing loss is essential to achieving normal language development.

Information on vision assessment and surveillance may be found in The American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, and the American Academy of Pediatrics Section on Ophthalmology.

Screening and Testing Using Standardized Methods

The provision of hearing or vision testing using a standardized instrument during the well child visit is billable on that service day as a distinct service. Hearing and vision testing using a standardized instrument is eligible for reimbursement when performed according to the DMAS periodicity schedule or when required to monitor the progression of hearing or vision loss related to the presence of identified risk factors. 

Virginia Law Regarding Hearing Screening at Birth

Virginia law requires that all infants receive a hearing screening before discharge from the hospital after birth. Those children who did not pass the newborn hearing screening, those who were missed, and those who are at risk for potential hearing loss should be scheduled for evaluation by a licensed audiologist.

Comprehensive Unclothed Physical Examination

A complete unclothed physical examination must be performed at each screening visit. The examination must be conducted using observation, palpation, auscultation and other appropriate techniques using the criteria for specific age groups described in the latest edition of the AAP Guidelines for Health Care Supervision. The examination must include all body parts (or areas) and systems listed below:

  • Cranium and face
  • Hair and scalp
  • Ears
  • Eyes
  • Nose
  • Throat
  • Mouth and teeth
  • Neck
  • Skin and lymph nodes
  • Chest and back (using a stethoscope) to check for heart and lung disorders
  • Abdomen
  • Genitalia
  • Musculoskeletal system
  • Extremities
  • Nervous system

 

The examination must include screening for congenital abnormalities and for responses to voices and other external auditory stimuli. Evaluation of the Tanner stage and scoliosis screening must be included as part of the complete physical examination at each screening visit beginning at age ten.

In addition, the height (or length) and weight of the child must be measured. When examining a child two (2) years of age and younger, the provider must measure the child’s occipital-frontal circumference. All measurements must be plotted on age-appropriate, standardized growth grids and evaluated.

Evaluation of growth and laboratory measures is useful for assessing nutritional status.  Assessing eating habits in relationship to developmental stage is also important. If dietary or nutritional problems are identified, a referral to the appropriate professional should be made.

For children three and above, the physical examination must include blood pressure measurement.

As part of the physical examination, excessive injuries or bruising that may indicate inadequate supervision or possible abuse must be noted in the child’s medical record. If there is suspicion or evidence that the child has been abused or neglected, State law requires medical professionals to promptly report it to the Department of Social Services’ Hotline 1-800-552-7096 (Code of Virginia Section-63-248.3).

Immunizations and Laboratory Tests

Age appropriate immunizations should be provided according to the Advisory Committee on Immunization Practices (ACIP) guidelines. All “catch up” schedules for missed vaccines should follow ACIP guidelines.

The child’s immunization status must be reviewed from the child’s medical record and interview with the parent at each screening visit. If the immunization history is based on the verbal report of the parents or other responsible adult, the information must be confirmed and properly documented, indicating the source.

Age-appropriate immunizations that are due must be administered during the screening visit.  Immunizations given to a child during a screening visit may be billed separately. PCPs and other medical screening providers are required to participate in the Virginia Vaccines for Children (VFC) Program and provide necessary immunizations and information about the benefits and risks of immunizations as part of EPSDT screenings. The PCP and screening provider must ensure that every child is immunized according to the current Childhood Immunization Schedule approved by ACIP and AAP. A parent’s refusal to allow immunizations must be documented by a statement in the child’s medical record that is signed and dated by the parent. If a condition is identified during the screening that warrants deferral of necessary immunizations to a later date, the progress notes in the medical record must so indicate. The provider must follow up to reschedule the child to catch up on immunizations at the earliest possible opportunity.

Counseling for COVID-19 vaccines is covered for all EPSDT-eligible members and may be billed separately for EPSDT-eligible members through the last day of the first quarter that begins one year after the last day of the COVID-19 federal public health emergency. Counseling for non-COVID-19 ACIP-recommended vaccines for all EPSDT-eligible members should be billed for under covered preventive care, well-child and Evaluation and Management (E&M) services.

Vaccines for Children Program

The Vaccines for Children (VFC) Program is a federal program established in 1984 to help raise childhood immunization rates in Virginia. VFC provides federally purchased vaccine, at no cost to health care providers, for administration to eligible children. As part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program, childhood immunizations and annual pneumococcal vaccinations are covered according to the most current Advisory Committee for Immunization Practices (ACIP) schedule.

To be eligible for free vaccine from the VFC Program, children must be under the age of 19.

VFC eligible individuals must also meet one of the following criteria:

  • Medicaid/FAMIS PLUS, enrolled, including Medicaid MCOs,
  • Uninsured (no health insurance),
  • Native American or Native Alaskans (no proof required) and
  • Underinsured (those whose insurance does not cover immunizations).

Requirement to Enroll in VFC

To participate, a provider must complete the enrollment and provider profile forms provided by VDH.  At this point, the provider is eligible to receive free vaccines under the VFC.

Upon enrollment, the Department of Medical Assistance Services will not reimburse the provider for the acquisition cost for vaccines covered under VFC. Medicaid will reimburse providers the administration fee for routine childhood vaccines that are available under VFC (under the age of 19). Medicaid will reimburse the provider an administration fee per injection.

Billing Codes for the Administration Fee

Providers must use Medicaid-specific billing codes when billing Medicaid for the administration fee for free vaccines under VFC. These codes identify the VFC vaccine provided and will assist VDH with its accountability plan that the Health Care Financing Administration (CMS) requires.  The billing codes are provided in the Current Procedural Terminology (CPT-4) books.

Billing Medicaid as Primary Insurance

For immunizations, Medicaid should be billed first for the vaccine administration. This is regardless of any other coverage that the child may have, even if the other coverage would reimburse the vaccine administration costs. Medicaid will then seek reimbursement from other appropriate payers. When a child has other insurance, check “YES” in Block 11-D (Is there another health benefit plan?) on the CMS-1500 (08-05) claim form. See the Physician/Practitioner Manual for further instructions.

Vaccines Not Available Under VFC

The Virginia Department of Health has no contracts with the Centers for Disease Control (CDC) for the VFC distributor to provide Diphtheria Tetanus and Pertussis (DTP) and Hepatitis B for dialysis patients. Therefore, Medicaid will reimburse for the acquisition cost for these vaccines under CPT codes 90701 and 90747, respectively. No administration fee will be reimbursed under code since this vaccine is not available under VFC.

Vaccines Provided Outside of the EPSDT Periodicity Schedule

Virginia Medicaid covers childhood immunizations under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit based upon a periodicity schedule. This schedule was developed by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics along with representatives from the American Academy of Family Physicians. If the provider provides a vaccine to a child that falls outside of this immunization schedule and the vaccine does not meet the criteria for coverage under the VFC Program, Medicaid will not reimburse for immunizations unless documentation is sent along with the claim to explain the circumstances under which the vaccine was provided.  In addition to the attachment to the claim, use modifier 22 in Locator 24-D to bill Medicaid for the acquisition cost.

Billing for Childhood Immunizations

The Federal Vaccines for Children (VFC) Program provides routine childhood immunizations free of charge to Medicaid-eligible children under the age of 19.  These vaccines are provided to VFC enrolled providers by the Virginia Department of Health (VDH). DMAS requires that PCPs serving children and EPSDT screening providers participate in the VFC program.  Providers may enroll in the VFC Program by contacting VDH at 1-800-568-1929. DMAS and the DMAS contracted MCOs will not reimburse providers for the acquisition cost of vaccines that are covered under the VFC Program. DMAS reimburses providers for the administration fee for routine childhood vaccines that are available under VFC (under the age of 19). DMAS will reimburse the provider an $11.00 administration fee per injection.

MCOs are responsible for provider payments of immunizations furnished to children enrolled in MCOs. Therefore, providers cannot be reimbursed by DMAS for immunizations provided to MCO enrolled children.

Reimbursement for Children Ages 19 and 20

Since EPSDT Federal regulations require states to provide coverage for vaccines for children under the age of 21, and VFC provides coverage only under the age of 19, there may be instances where the provider will provide immunizations to children who are ages 19 and 20. In these instances, the provider must use the appropriate CPT procedure code. DMAS will reimburse the acquisition cost for these vaccines. The charges in locator 24F of the HCFA 1500 (12-90) claim form must reflect the actual acquisition cost per dose. Providers should refer to Chapter V of the DMAS Physician Manual for further billing guidance. 

VFC Coverage of Other Vaccines

The VFC program covers all vaccines in the ACIP immunization schedule, including indications for when a single-antigen vaccine that is normally part of a combination vaccine may be medically appropriate. Claims for single-antigen vaccines that are normally a part of a combination vaccine will automatically pend for review by DMAS staff.

Age appropriate immunizations are a federally required screening component.  The provider must not submit a claim for a complete screening unless all required components that are due are administered and documented including appropriate immunizations according to age and history (unless medically contraindicated or the parents refuse at the time). Failure to comply with or properly document this screening requirement must constitute an incomplete screening and may result in denial of payments.

EPSDT REQUIREMENTS FOR LEAD TESTING

As part of the definition of EPSDT services, the Medical Statute requires coverage for children to include both screening and blood lead tests as appropriate, based on age and risk factors. The Centers for Medicare and Medicaid Services (CMS) requires all Medicaid enrolled children receive a blood lead test at 12 months and 24 months of age. In addition, any child between 24 and 72 months with no record of a previous blood lead screening test must receive one. The medical record will be deemed insufficient if the child has not been previously screened. Completion of a risk assessment questionnaire does not meet the Medicaid requirement. The Medicaid requirement is met only when the two blood lead screening tests identified above (or a catch-up blood lead screening test) are conducted

(https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.pdf).

Confirmation of Blood Lead Levels

Blood Lead level testing shall be performed on venipuncture or capillary blood; however, additional testing may be required, as described below. Filter paper methods are also acceptable and can be performed at the provider’s office. The use of handheld testing machines must be approved through the Lead-Safe Virginia Program to assure proper quality assurance and reporting of data.

 

Tests of venous blood performed by a laboratory certified by the federal Centers for Medicare & Medicaid Services in accordance with 42 USC § 263a, the Clinical Laboratory Improvement Amendment of 1988 (CLIA-certified), are considered confirmatory. Tests of venous blood performed by any other laboratory and tests of capillary blood shall be confirmed by a repeat blood test, preferably venous, performed by a CLIA-certified laboratory. Such confirmatory testing shall be performed in accordance with the following schedule (requirements of 12VAC5-90-215):

 

If result of screening test (μg/dL) is:

Perform diagnostic test on venous blood within:

5-9

1- 3 months

10-44

1 week – 1 month

45-59

48 hours

60-69

24 hours

70 or higher

Immediately as an emergency lab test

 

 

 

 

 

 

 

 

 

                                                                                                                                

For consultation and assistance on the treatment of children with elevated venous blood levels 70 or higher contact Emergency Lead Healthcare through their free medical hotline at 1-866-767-5323 (1-866-SOS-LEAD).

Lead Testing Procedure Codes

If blood lead screening tests are conducted in the providers’ offices, the code 83655 for Lead blood testing is used with one of the following: 36416 or 36415, depending on whether the sample is from a capillary or venous site, as shown below.

 

   Service Description

Procedure Code

Lead Lab Test

(paid to Lab or EPSDT screener)

CPT 83655

Capillary Sample (finger, heel, ear stick)

CPT 36416

Venous Sample (recommended)

CPT 36415

 

When blood lead testing is provided to a client enrolled in a Virginia Medicaid Managed Care Organization (MCO), please follow the MCOs specific billing instructions.

 

Remember to always verify Medicaid eligibility before services are rendered.

Virginia Regulations for Disease Reporting and Control

The Virginia Regulations for Disease Reporting and Control require physicians and the directors of laboratories to report any “detectable” blood lead levels in children ages 0-15 years to the Local Health Department within 3 days.

 

In October 2016, these regulations were updated and “Lead, elevated blood levels” was renamed “Lead, reportable levels”. “Lead, reportable levels” now means any detectable blood lead level in children 15 years of age and younger and levels greater than or equal to 5 μg/dL in a person older than 15 years of age (12VAC5-90-10). This requirement applies to test results confirmed by a CLIA-certified laboratory. Results of office-based screening tests do not need to be reported.

Many laboratories submit disease reports by means of secure electronic transmission. Reports may also be submitted by using the Epi-1 form that can be found on the Virginia Department of Health (VDH) web site at: http://www.vdh.virginia.gov/content/uploads/sites/13/2016/03/Epi1.pdf

 

For more information, please visit the VDH web site:

http://www.vdh.virginia.gov/surveillance-and-investigation/commonwealth-of-virginiastate-board-of-health/

Medicaid Funded Environmental Investigations

Environmental investigations are a service offered by Medicaid through Lead-Safe Virginia and local health departments. Environmental investigations are reimbursed to local health departments enrolled with DMAS or contracted with a Virginia Medicaid MCO. Medicaid funds are not available for the testing of environmental substances such as water, paint, or soil. Environmental investigations are conducted when certain criteria are met and may be carried out by private entities or environmental health specialists in local health departments who are licensed risk assessors. For information about what triggers an environmental lead investigation and what it includes, go to http://www.vdh.virginia.gov/leadsafe.

 

For additional questions about environmental lead testing, contact Lead-Safe Virginia toll-free at 1-877-668-7987. You may also email Lead-Safe Virginia at leadsafe@vdh.virginia.gov.

 

Resources for more information about blood lead testing and lead exposure

Lead-Safe Virginia:

https://www.cdc.gov/nceh/lead/programs/va.htm

The National Lead Information Center (NLIC):

Environmental Protection Agency (EPA):

https://www.epa.gov/lead

CDC Childhood Lead Poisoning Prevention Program

https://www.cdc.gov/nceh/lead/

Coalition to End Childhood Lead Poisoning:

http://www.greenandhealthyhomes.org/StrategicPlanforEndingLeadPoisoning

Additional Laboratory Procedures

In addition to the lead toxicity screening, the following procedures on laboratory tests are required:

Neonatal Screening

The screening provider must review the results of the newborn metabolic screening for phenylketonuria, hypothyroidism, galactosemia and other disorders performed prior to hospital discharge.

Sickle Cell Screening

The screening provider must review the results of the sickle cell screening performed prior to hospital discharge on the appropriate population.  A sickle cell preparation must be done at the six (6) month old visit if indicated in accordance with AAP guidelines.

Anemia Screening

Iron deficiency anemia screening involving taking hematocrit or hemoglobin values through a finger prick or venous blood sample must be performed at screening visits in accordance with AAP guidelines.

Anemia screening, is a Medicaid reimbursable service, and should be administered more frequently if medically indicated.  The results can be shared with the patient’s written consent if the certification is needed for the Supplemental Nutrition Program for Women, Infants and Children (WIC).

EPSDT Optional Screening Procedures

The following is a description of optional screening procedures to be performed on children and adolescents at risk:

Tuberculin Test (Optional)

Tuberculin testing using the Purified Protein Derivative (PPD) skin test should be performed in accordance with AAP guidelines.  The PPD test has replaced the Tyne method.

Cholesterol Screening (Optional)

Cholesterol and hyperlipidemia screening should be performed at each screening visit beginning at age two in accordance with AAP guidelines.

Sexually Transmitted Disease (STD) Screening (Optional)

All sexually active adolescents should be screened for sexually transmitted diseases such as chlamydia, gonococci, and syphilis at each screening visit beginning at age 11 through age 20.  HIV testing should be performed if requested or if the adolescent is at high risk.

Cancer Screening (Optional)

A Papanicolaou (Pap) smear should be performed on all sexually active females at each screening visit.

Pelvic Examination (Optional)

All sexually active females should have a pelvic examination. A pelvic examination and a Pap smear must be offered as part of preventive health maintenance between the ages of 18 and 21.

Anticipatory Guidance

Health Education, also called “Anticipatory Guidance”, and problem focused guidance and counseling are provided at each well child visit according to developmental needs and with respect to patient cultural backgrounds and literacy levels.

The Bright Futures program has family friendly materials that provide useful anticipatory guidance information and age appropriate safety and parenting tips. For more information on Bright Futures, go to the web based training module at http://www.vdh.virginia.gov/brightfutures DMAS endorses Bright Futures and Bright Futures Virginia.

Referral to Dental Screening

Federal EPSDT regulations require a direct referral to a dentist beginning at age three.  An oral inspection must be performed by the EPSDT screening provider as part of each physical examination for a child screened at any age. Tooth eruption, caries, bottle tooth decay, developmental anomalies, malocclusion, pathological conditions or dental injuries must be noted.  The oral inspection is not a substitute for a complete dental screening examination provided through direct referral to a dentist. 

The PCP or other screening provider must make an initial direct referral to a dentist when the child receives his or her three-year screening. The initial dental referral must be provided at the initial medical screening regardless of the periodicity schedule on any child age three or older unless it is known and documented that the child is already receiving regular dental care.  The importance of regular dental care must be discussed with the family (and child as appropriate) on each screening visit for children three (3) years and older. When any screening, even as early as the neonatal examination, indicates a need for dental services at an earlier age, referral must be made for needed dental services.

DOCUMENTATION

The screening provider must retain copies of all screening claims and other Medicaid claims for at least five years from the date of service or as provided by applicable state laws, whichever period is longer.  If an audit is initiated within the required retention period, the records must be retained until the audit is completed and every exception resolved. The PCP must maintain complete medical records on all children screened in his or her panel for at least five years from the date of service or as provided by applicable state law, whichever period is longer.  Appropriate procedures and systems to ensure confidentiality must be in place.  Medical records must contain the following information specific to EPSDT screening services:

  • Reason for visit, e.g., screening, follow-up, sick visit.  (Note the complaint and relevant history).
  • The date screening services were performed, the specific tests or procedures performed, the results of these tests and procedures, and the specific staff member who provided the service.  Each required component of screening including vision and hearing screening and immunizations must be documented separately. The DMAS-353, available in the provider portal, may be used for this purpose.
  • Documentation of medical contraindication or a written statement from a parent or a guardian on a child screened for whom immunizations were due and not given and attempts the screening provider made to bring the child up-to-date on immunizations.
  • Identification of any screening component not completed, the medical contraindication or other reason why it could not be completed, and attempts the screening provider made to complete the screening.
  • Documentation of a medical contraindication or other reason for delay in vision or hearing screening if not performed on the same day as a medical screening.
  • Documentation of declination of screening services by parents.
  • Documentation of missed appointments and of at least two good faith efforts to reschedule according to the periodicity schedule.
  • Referrals made for diagnosis, treatment, or other medically necessary health services for conditions found in screenings and documentation of follow-up done to assure services or treatment were provided within 60 days of the screening.
  • Date next screening is due.
  • Documentation of direct referral for age-appropriate dental services.

SPECIAL BILLING INSTRUCTIONS

Virginia Medicaid requires the use of Health Care Financing Administration Common Procedure Coding System (HCPCS/CPT) codes and definitions published in the current edition of the Physician’s Current Procedural Terminology (CPT) in billing EPSDT covered screenings.  The CPT Manual may be obtained by calling the America Medical Association at 1-900-621-8335. The Health Insurance Claim Form, CMS-1500 (08-05) must be used to bill for screening services and immunizations.  The invoice is completed and submitted according to the instructions provided in the Medicaid Physician Manual. Locators 24D and 24H are specific to EPSDT screening claims.  The appropriate procedure modifier is required in locator 24D for each CPT code for screeningsThe appropriate indicator “1” is required in locator 24H.

Referral providers authorized by a child’s PCP to provide treatment or other health services to that child must enter the Medicaid Provider Identification Number of the PCP in Locator 17a of the CMS-1500 (08-05)  in order to be reimbursed. Subsequent referrals resulting from the PCP’s initial referral will also require the PCP’s authorization and the PCP’s Medicaid provider number in this block.

For children enrolled in MCOs, the MCO is responsible for payment of EPSDT screening services.

Billing for Developmental Screenings

Assessment and screening is a reimbursable service when a standardized screening tool is used.  Providers may bill for a developmental screening or assessment, using the Current Procedural Terminology (CPT) code 96110, (E&M) visit when Modifier 25 is used along with the appropriate E&M code (CPT codes 99201-215 and 99381-395) for that visit.    

Providers may use the following modifiers, when appropriate as defined by the most recent (CPT).  The member’s medical record must contain documentation to support the use of the modifier by clearly identifying the significant, identifiable service, and tool used that allowed the use of the modifier.

  • Modifier 22 – Unusual Procedural Service: When the service provided is greater than that usually required for the procedure code.  Use of this modifier will cause the claim to pend for manual review and requires an attachment to explain the use of the modifier.  Physicians should not apply this modifier unless there are unusual situations that warrant manual review.
  • Modifier 24 – Unrelated E&M Service by the same Physician during the post-operative period.
  • Modifier 25 – Significant, separately identifiable E&M Service on the same day by the same Physician on the same day of the procedure or other services.
  • Modifier 59 – Distinct Procedural Service

This section describes how to claim an EPSDT periodic screening or well-child visit and when to bill for an inter-periodic or problem focused visit in lieu of a well child visit.  A list of the Current Procedural Terminology (CPT) codes used to reimburse for well child visit services is included in the “Exhibits” section of this chapter. 

Screening/Well Child Billing Guidance

  • Complete Well Child/EPSDT Screening (CPT 99381-99395): Bill the appropriate evaluation and management (E&M) code for Preventive Medicine Services (screening) when all services included in the procedure code as described in the Current Procedural Technology (CPT) manual are completed and documented.  Use the ICD diagnosis codes for a “healthy visit.”
  • Incomplete EPSDT Screening (CPT 99381-99395): If screening is incomplete because the child is uncooperative, bill the E&M code for an appropriate office visit and reschedule the child for the next appropriate EPSDT screening/well child visit.  Use the ICD diagnosis code that defines the child’s health status for this “problem focused” visit.
  • Problem Focused or Inter-periodic Screening “Sick Visit” (99201-99215): These are problem-focused screenings that are used to investigate specific health complaints and to refer children for any type of medical or mental health treatment. Use the ICD diagnosis code that defines the child’s health status for this visit. The screening provider may not bill for a separate office visit for treatment of the child’s illness or condition on the date a complete screening is billed.

Billing for Hearing, Vision, and Developmental Screenings During the EPSDT Well Child or Problem Focused Visit

Objective hearing screening (CPT code 92551), vision screening (CPT code 99173), and developmental assessment (CPT code 96110) procedures performed using a standardized screening method on the same date of service as a Preventive Medicine E&M will be reimbursed separately when Modifier 25 is used along with the appropriate E&M code for that visit. 

Use the following modifiers, when appropriate as defined by the most recent Current Procedural Terminology (CPT). The member’s medical record must contain documentation to support the use of the modifier by clearly identifying the significant, identifiable service that allowed the use of the modifier.

 

  • Modifier 22 – Unusual Procedural Service: When the service provided is greater than   that usually required for the procedure code.  Use of this modifier will cause the claim to pend for manual review and requires an attachment to explain the use of the modifier.  Physicians should not apply this modifier unless there are unusual situations that warrant manual review.
  • Modifier 24 – Unrelated E&M Service by the same Physician during the post-operative period.
  • Modifier 25 – Significant, separately identifiable E&M Service on the same day by the same Physician on the same day of the procedure or other services.
  • Modifier 59 – Distinct Procedural Service

Billing for Special or Inter-periodic EPSDT Screenings (Medicaid Fee-for-Service Providers)

  • Missed Screenings - If a child misses a regular periodic screening, that child may be screened at the earliest possible time to bring the child into compliance with the AAP-recommended periodicity schedule. Providers should follow billing instructions for an EPSDT/Well Child screening.

 

  • Inter-periodic Screenings - Screenings may be provided in addition to the regular periodicity schedule screenings for medical evaluation of a specific problem. Inter-periodic screenings may be billed as a sick visit however, it cannot be used to provide a school, Head Start or sports physical when a well child visit was provided earlier that year.  If a screening is needed to examine a specific issue or complete a developmental or comprehensive history related to a specific medical issue, then an inter-periodic screening can be provided using the appropriate preventive medicine codes.  Any caregiver, medical provider or a qualified health, developmental, or educational professional who comes in contact with the child outside of the formal health care system may request that an evaluative inter-periodic screening be performed. These screenings require a brief narrative justifying the additional inter-periodic screen in the medical record. Providers should submit inter-periodic preventive and objective screening claims with a 22 Modifier to the procedure code, attach the justification statement to the claim and write “Attachment” in Locator 10D of the CMS 1500 claim form for proper processing.

 

  • School Entry, Headstart, and Sports Physicals - Headstart/school entry and participation in athletics often create opportunities to screen children who are not current for Well Child/EPSDT screenings.  If the child is not current with the Well Child/EPSDT schedule, complete the age appropriate Well Child/EPSDT screen.  If the child is current with the Well Child/EPSDT schedule, a request for a Headstart/School Entry or Sports Physical does not justify the need for an inter-periodic medical screening.  Providers may document the Well Child/EPSDT screening based on the School Entrance physical forms.  However the physical exam is not a covered service when the child is current with his or her well child visit schedule.

Billing for Laboratory Tests

The screening provider may bill separately for laboratory tests that are performed as part of the screening and documented in the child’s medical record.  DMAS will only reimburse the provider actually performing the service (i.e., physician, independent laboratory, or other facility).  The screening provider may bill for incurred handling and shipping charges on the HCFA-1500 (12-90) when the specimens are sent to an outside laboratory.

Lead Testing Claims Process

A list of lead testing procedure codes is included in the “EPSDT Screening Procedure Codes” exhibit at the end of this chapter. When lead testing is provided during a well child visit or other health care encounter, the EPSDT screener must use the lead testing procedure codes with a “25” modifier in block 24D of the CMS-1500 Claim Form. Independent Laboratories or EPSDT screeners that have an approved laboratory will bill the 83655 code when the lead test is performed. 

If blood lead screening tests are conducted in the provider’s offices, the code 83655 for Lead blood testing is used with one of the following: 36416 or 36415, depending on whether the sample is from a capillary or venous site.

A comprehensive list of Medicaid-enrolled lab providers may be found by contacting the DMAS Provider HELPLINE, or by accessing the DMAS web portal at   http://www.dmas.virginia.gov/#/maternalepsdt.

When blood lead testing is provided to a client enrolled in a Virginia Medicaid Managed Care Organization (MCO), the provider should follow the MCOs specific billing instructions.  Providers should always verify Medicaid eligibility before services are rendered.  DMAS offers a web-based Internet option (ARS) to access information regarding Medicaid or FAMIS eligibility. The web portal to enroll for access to this system is:

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. The MediCall voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.

VFC or Immunization Billing Questions

For questions relating specifically to the VFC program vaccines, contact the Virginia Department of Health Hotline at 1-800-568-1929.  The VDH Hotline is available Monday through Friday from 7:00 a.m. to 5:00 p.m.  For billing questions, contact the Medicaid Provider Help Line at 1-800-552-8627.

Office Visits Billed in Conjunction with Immunizations

DMAS will reimburse physicians an appropriate minimal office visit in addition to the VFC administration fee (or acquisition cost for adolescents ages 19 and 20 only) when an immunization is the only service performed. 

EPSDT REFERRALS for Specialized Services

When an EPSDT screening indicates the need for diagnosis or treatment for a suspected condition or abnormality, the physicians’ progress notes must so indicate. The child may be referred for medically necessary specialty care or other health services if the PCP or screening provider is not able to provide the treatment. If the screening provider is not the child’s PCP, the screening provider must contact the child’s PCP to request a referral and authorization for the treatment or other services.

The PCP must follow up on all EPSDT referrals resulting from a screening to ensure that the child receives the requested treatment or other services within 60 days and document the results in the child’s medical record.

The Omnibus Budget Reconciliation Act of 1989 requires states to reimburse for medically necessary services not otherwise covered under the State Plan for Medicaid-eligible children up to the age of 21 when such services are needed to correct or ameliorate defects, and physical and mental illness and conditions discovered by the screening services, as long as the services are allowable under the Social Security Act 1905(a) and are authorized by DMAS or its contractors.

Some services are available outside of the State Plan under Social Security Act Section 1915(c) through Home and Community-Based Services Waivers.  Services covered under Section 1915(c) are not covered under EPSDT unless they are also allowable services under Section 1905(a).  For more information on Home and Community-Based Waivers, providers may contact the DMAS Provider Call Center at 1‑800-552-8627 or refer to http://www.dmas.virginia.gov/#/ltss

SERVICE AUTHORIZATION FOR SPECIALIZED SERVICES

Any treatment service that is not otherwise covered under the State’s Plan for Medical Assistance can be covered for a child through EPSDT as long as the service is allowable under the Social Security Act Section 1905(a) and the service is determined by the Department of Medical Assistance Services (DMAS) or its contractor as medically necessary.  Treatment services that are approved through the EPSDT benefit but are not available through the State Plan for Medical Assistance are called EPSDT Specialized Services. 

Reimbursement for EPSDT specialized services is limited to the hours of treatment and medical or clinical supervision as specified in the treatment plan and as approved by DMAS or its contractors. All specialized service requests require physician documentation outlining the medical necessity, frequency and duration of the treatment. To qualify for reimbursement through the EPSDT benefit  EPSDT specialized services must be approved before the service is rendered by the provider. Please see Appendix A to this supplement for additional information.

Detailed information on the service authorization of behavioral therapy, nursing, personal care inpatient services and audiology and hearing aid services defined as “Specialized Services” under EPSDT is available in separate EPSDT chapters and Appendix A available on the DMAS web portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. DMAS or its contractor service authorizes other services through the EPSDT benefit such as Residential Treatment for persons with developmental and behavioral challenges, hospital based services to treat neurological conditions, bariatric related treatment, treatment for eating disorders and treatment for other chronic health conditions. The services available through EPSDT are not limited to those listed.  Please see Appendix A for additional information.

Chiropractic Services

 Chiropractic services are available for Medicaid members under the age of 21 and through the DMAS EPSDT benefit. This service cannot be authorized for Medicaid members age 21 and older. Chiropractors (Provider Type 026) are the only providers to submit these requests. DMAS or its contractor will apply McKesson InterQual® to certain services and DMAS criteria where McKesson InterQual® products do not exist. If unable to approve a request, then DMAS or its contractor will apply EPSDT criteria. The Chiropractic CPT codes requiring service authorization are listed below.

Chiropractic CPT codes to submit for service authorization:

98940  CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, ONE TO TWO REGIONS

 

98941 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, THREE TO FOUR REGIONS

 

98942 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, FIVE REGIONS

 

98943 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, ONE OR MORE REGION

Please see Appendix A for additional service authorization information.

Review of Items Denied Under DME for Coverage through EPSDT

In addition to the traditional review of requests for Durable Medical Equipment and Supplies (DME), children enrolled in either FAMIS Plus and FAMIS Fee for Service who are initially denied services under the DME program will receive a secondary review for these items using the EPSDT “correct or ameliorate” approval criteria. Some of these services will be approved by the DMAS service authorization contractor under the already established criteria for that specific item/service and will not require a separate review under EPSDT; some service requests may be denied using specific item/service criteria and need to be reviewed under EPSDT; and some may be referred to DMAS by its contractor on a case-by-case basis. Specific information regarding the methods of submission for children enrolled in FFS may be found at the contractor’s website, https://dmas.kepro.com/.  The contractor may also be reached by phone at 1-888-VAPAUTH or 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.  Providers should contact the MCO for DME requests for children enrolled in managed care.

For additional information on the service authorization of DME, please see Appendix D of the DME Provider Manual. A copy of this manual is available on the DMAS Medicaid web portal.

Service Authorization Status:

DMAS offers a web-based Internet option (ARS) to access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, service authorization, and pharmacy prescriber identification. The DMAS web portal to enroll for access to this system is https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. The MediCall voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.

Assistive Technology

To correct or ameliorate physical or mental conditions identified during EPSDT screening services, the child may be referred by the EPSDT screener or PCP for Assistive Technology services. Assistive Technology is defined as specialized medical equipment, supplies, devices, controls, and appliances not available under the Virginia State Plan for Medical Assistance. Assistive Technology items directly enable individuals to increase their abilities to perform ADLs or to perceive, control, or communicate with the environment in which they live. Assistive Technology items are expected to be portable.

To meet the definition of Assistive Technology, requested items must meet all of the following requirements.  Assistive Technology must:

  • be able to withstand repeated use;
  • be primarily and customarily used to serve a medical purpose and be medically necessary and reasonable for the treatment of the individual’s disability or to improve a physical or mental condition;
  • generally be not useful to a person in the absence of a disability, physical or mental condition; and
  • be appropriate for use in both the home and community.

Equipment or supplies already covered by the Virginia State Plan for Medical Assistance may not be requested for reimbursement under EPSDT. A list of covered items is located in the Durable Medical Equipment and Supplies Provider Manual that is available on the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual. Providers may use the “Medicaid DME and Supplies Listing” located in Appendix B of this manual to ascertain whether an item is covered through the Virginia State Plan for Medical Assistance before requesting the item through EPSDT. Equipment and supplies must be provided by a DME provider or assistive technology provider. 

Criteria

Only Assistive Technology items that are determined to be medically necessary may be covered for reimbursement by DMAS. The following criteria must be satisfied through the submission of adequate and verifiable documentation satisfactory to DMAS. Assistive Technology must be:

  • Ordered by a physician to correct or ameliorate physical or mental conditions identified during EPSDT screening services;
  • A reasonable and medically necessary part of a treatment plan;
  • Consistent with the individual’s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the individual;
  • Not furnished solely for the convenience of the family, attending physician, or other practitioner or supplier;
  • Consistent with generally accepted professional medical standards (i.e., not experimental or investigational); and
  • Provided at a safe, effective, and cost-effective level that is suitable for use by the individual.

Assistive Technology must involve direct support to the individual and be for the express purpose of diagnosing, treating or preventing (or minimizing the adverse effects of) illness, injury or other impairments to an individual’s physical or mental health.  Therefore, services that do not involve direct support to the individual or environmental services dealing exclusively with an individual’s surroundings rather than the individual are not covered.  Further, even if the requested service does involve some direct support for the individual, it cannot be covered unless the device is related to the diagnosis given as the reason for the service request

Home/Environmental modifications do not meet the definition of Assistive Technology and are not covered under EPSDT services. Environmental modifications are defined as physical adaptations to an individual’s home, primary place of residence, vehicle, or workplace. Examples of environmental modifications include but are not limited to devices that are permanently affixed to the walls of the home such as grab bars, ramps, barrier free lifts, and widening of doorways.

Individuals and caregivers are responsible for determining if the individual is receiving the appropriate Assistive Technology in the school system and suggesting that the child’s Individualized Education Plan (IEP) include Assistive Technology.  In cases where Assistive Technology is requested for use during school hours and not included in the IEP, the provider must obtain documentation from the school indicating why the Assistive Technology is not included in the child’s IEP. Items covered under the Individuals with Disabilities Education Act (IDEA) cannot be covered under EPSDT. For information regarding Medicaid covered school services, please see the School Health Services Manual located on the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual.

Service Authorization Requirements

All Assistive Technology items must be authorized by DMAS or its contractor. Service authorization for children enrolled in Managed Care must be obtained through the MCO.  Please see Appendix A for additional information. Each Assistive Technology item must be recommended and determined appropriate to meet the individual’s needs by a qualified professional such as an occupational therapist, physical therapist, speech language pathologist or behavioral consultant. 

Medical documentation must provide a clear understanding of the individual’s needs. Documentation for each requested Assistive Technology item must identify:

  • The medical need for the requested Assistive Technology;
  • The diagnosis related to the reason for the Assistive Technology request;
  • The individual’s functional limitation and its relationship to the requested Assistive Technology item;
  • How the Assistive Technology item will treat the individual’s medical condition;
  • The quantity needed and the medical reason the requested amount is needed;
  • The frequency of use;
  • The estimated length of use of the item;
  • Any conjunctive treatment related to the use of the item;
  • How the needs were previously met and identifying changes that have occurred which necessitate the Assistive Technology request;
  • Other alternatives tried or explored and a description of the success or failure of these alternatives;
  • How the Assistive Technology item is required in the individual’s home or community environment; and
  • The individual’s or caregiver’s ability, willingness, and motivation to use the Assistive Technology item.

Provider Documentation Requirements

Documentation requirements include:

  1. Supporting documentation, which includes the need for the service, the process to obtain this service (contacts with potential vendors or contractors, or both, of service, costs, etc.); and the time frame during which the service is to be provided. This includes separate notations of evaluation, design, labor, and materials.
  2. Written documentation which proves that the item was requested and was not approved by the Virginia State Plan for Medical Assistance as Durable Medical Equipment and Supplies;
  3. Documentation of the date services are rendered and the amount of service needed;
  4. Any other relevant information regarding the device or modification;
  5. Documentation of the satisfaction of the individual and/or the individual’s family with the service
  6. Instructions regarding any warranty, repairs, complaints, or servicing that may be needed. and
  7. The individual’s or caregiver’s ability to use the Assistive Technology item effectively.

Specific information regarding the methods of submission for individuals enrolled in FFS are found at the contractor’s website, https://dmas.kepro.com/ The contractor may also be reached by phone at 1-888-VAPAUTH or 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.

There are no automatic renewals of service authorizations. Providers must submit a service authorization request if a member requires continued services or the current authorization will end without renewal. All authorizations should be submitted prior to the first date services are rendered or prior to the last day of the current authorization in order for submissions to be timely and to avoid any gaps in service. 

For additional information on the service authorization process, please refer to Appendix A to this Supplement.

Medical Formula Covered As Durable Medical Equipment (DME)

The Early Periodic Screening Diagnosis and Treatment (EPSDT) benefit allows the Virginia Department of Medical Assistance Services (DMAS) to provide medically necessary formula and medical foods to EPSDT eligible children under the age of 21 based on medical necessity. The current DMAS Durable Medical Equipment (DME) provider manual defines EPSDT formula approval criteria in Chapter 4 of that manual. Routine infant formula is not covered. DMAS will reimburse for medically necessary formula and medical foods when used under physician direction to augment dietary limitations or provide primary nutrition to individuals via enteral or oral feeding methods. 

Medical formula and nutritional supplements must be physician recommended to correct or ameliorate a health condition that requires specialized formula and medical foods to supplement diet due to metabolic limitations or provide primary nutrition to individuals via enteral or oral feeding methods. Enrollees under the age of five may receive medical formula and nutritional supplements through either a local Women, Infants and Children (WIC) office or a DMAS enrolled DME provider.  If the individual is enrolled in the WIC program, they also receive nutrition education services and checkups as well as referrals to other services that can help the family.  Individuals enrolled in Medicaid may already financially qualify for WIC. When a local WIC office provides the formula for children under the age of five then the WIC program forms are used to document medical necessity. Please refer to the DME provider manual for additional information.

OTHER RELATED PROGRAMS

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

WIC is a supplemental food and nutrition education program that provides vouchers for the purchase of specific nutritious foods and provides nutrition counseling to pregnant, postpartum, or breastfeeding women and children under age five with nutritional and financial needs.  PCPs and EPSDT screening providers must refer Medicaid-eligible individuals in these categories to the local health department for additional information and eligibility determination.

Head Start

Head Start is a federally funded pre-school program which serves low-income children and their families.

There are four major components in Head Start as follows:

  • Education¾Head Start’s educational program is designed to meet the individual needs of each child.  It also aims to meet the needs of the community served and its ethnic and cultural characteristics;
  • Health¾Head Start emphasizes the importance of early identification of health problems.  Since many children of low-income families have never seen a doctor or dentist, Head Start provides every child with a comprehensive health care program, including medical, dental, mental health, and nutritional services.  The comprehensive EPSDT screening will meet the requirements of the Head Start Program health assessment;
  • Parent Involvement¾Parents are the most important influence on a child’s development.  Parents are encouraged to participate in the Head Start program as volunteers or paid staff as aides to teachers and other staff members.  Many parents serve as members of Policy Councils and committees and have a voice in administrative and managerial decisions;
  • Social Services¾The social services component of Head Start represents an organized method of assisting families to assess their needs, and then providing those services that will build upon the individual strengths of families to meet those needs.  Some of the activities that the social services staff use to assist families to meet their needs are:  community outreach; referrals; family needs assessments; providing information about available community resources and how to obtain and use them; recruitment and enrollment of the children; and emergency assistance and/or crisis intervention.

Early Intervention Program

Early intervention services are identified in the Part C amendment to the Individuals with Disabilities Education Act (IDEA). Part C provides for a discretionary grant program for states to plan, develop and implement a statewide, comprehensive, coordinated, interagency system of early intervention services to infants and toddlers with disabilities and their families.

Infant & Toddler Connection of Virginia/DMAS Early Intervention Program

The Infant & Toddler Connection of Virginia assists families of infants and toddlers with developmental delays and/or disabilities to help their children learn and develop through everyday activities and routines so that they can participate fully in family and community activities. Since there are no income limits for this program, all children who meet the early intervention eligibility criteria and who are under the age of three are eligible to receive early intervention services.  In order to take advantage of the services and supports available, families need to know about the system and how to access these resources.  More information can be found about the Infant & Toddler Connection of Virginia at:  http://www.infantva.org/

 

Who is eligible for the Infant and & Toddler Connection of Virginia?

 

Infants and toddlers with 25% or greater delay in one or more developmental area(s):

Cognitive, adaptive, receptive or expressive language, social/emotional, fine motor, gross  

motor vision, hearing development

 

Infants and toddlers with atypical development – as demonstrated by atypical/ questionable:

Sensory-motor responses, social-emotional development, or behaviors, or impairment in    social interaction and communication skills along with restricted and repetitive behaviors

 

Infants and toddlers with a diagnosed physical or mental condition that has a high

probability of resulting in developmental delay:

e.g., cerebral palsy, Down syndrome or other chromosomal abnormalities, central nervous system disorders, effects of toxic exposure, failure to thrive, etc.

Referral information and contact information can be found online at https://www.itcva.online/central-directory

For more information, contact:

Infant & Toddler Connection of Virginia

DBHDS, 9th Floor

1220 Bank Street

PO Box 1797

Richmond, Va. 23218-1797

(804)786-3710

(804)371-7959 Fax

www.infantva.org

Smart Beginnings

Virginia's Plan for Smart Beginnings brings together the public agencies, private agencies and organizations that support Virginia’s children and families to ensure that these efforts are both effective and well coordinated. The purpose of Virginia’s Plan for Smart Beginnings is to build and sustain a system in Virginia to support parents and families as they prepare their children to arrive at kindergarten healthy and ready to succeed.  More information regarding this program can be found at www.smartbeginnings.org.

PROVIDER SCREENING REQUIREMENTS

All providers must now undergo a federally mandated comprehensive screening before their application for participation or contract is approved by the MCOs, Behavioral Health Services Administrator (BHSA), a DMAS contracted Medicare and Medicaid Plan (MMP) or DMAS. Screening is also performed on a monthly basis for any provider who participates with Virginia Medicaid. A full screening is also conducted at time of revalidation, in which every provider will be required to revalidate at least every 5 years.

The required screening measures are in response to directives in the standards established by Section 6401(a) of the Affordable Care Act in which CMS requires all state Medicaid agencies to implement the provider enrollment and screening provisions of the Affordable Care Act (42 CFR 455 Subpart E). These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011. The required screening measures vary based on a federally mandated categorical risk level. Providers categorical risk levels are defined as “limited”, “moderate” or “high”. Please refer to the table in the Exhibits of this chapter for a complete mapping of the provider risk categories and application fee requirements by provider class type.

Limited Risk Screening Requirements

The following screening requirements will apply to limited risk providers: (1) Verification that a provider or supplier meets any applicable Federal regulations, or State requirements for the provider or supplier type prior to making an enrollment determination; (2) verification that a provider or supplier meets applicable licensure requirements; and (3) federal and state database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type and that they are not excluded from providing services in federally funded programs.

Moderate Risk Screening Requirements

The following screening requirements will apply to moderate risk providers: Unannounced pre- and/or post-enrollment site visits in addition to those screening requirements applicable to the limited risk provider category listed above. The screening requirements listed in this section are to be performed at the time of initial enrollment and at the time of revalidation, which is at least every five years.

High Risk Screening Requirements

In addition to those screening requirements applicable to the limited and moderate risk provider categories listed above, providers in the high risk category may be required to undergo criminal background check(s) and submission of fingerprints. These requirements apply to owners, authorized or delegated officials or managing employees of any provider or supplier assigned to the “high” level of screening. At this time, DMAS is awaiting guidance from CMS on the requirements of criminal background checks and finger prints. All other screening requirements excluding criminal background checks and finger prints are required at this time.

Application Fees

All newly enrolling (including new locations), re-enrolling, and reactivating institutional providers who are enrolling with DMAS or the BHSA and meet the provider types indicated in the Appendix of this Chapter are required to pay an application fee set forth in Section 1866(j)(2)(C) of the Social Security Act and 42 CFR 455.460. If a provider class type is required to pay an application fee, it will be outlined in the Virginia Medicaid web portal provider enrollment paper applications, online enrollment tool, and revalidation process. Providers shall refer to the specific MCOs and MMPs for any additional requirements. The Centers for Medicare and Medicaid Services (CMS) determine what the application fee is each year. This fee is not required to be paid to Virginia Medicaid if the provider has already paid the fee to another state Medicaid program or Medicare, or has been granted a hardship approval by Medicare.

Providers may submit a hardship exception request to CMS. CMS has 60 days in which to approve or disapprove a hardship exception request. If CMS does not approve the hardship request, then providers have 30 days from the date of the CMS notification to pay the application fee or the application for enrollment will be denied. An appeal of a hardship exception determination must be made to CMS as described in 42 CFR 424.514.

Out-of-State Provider Enrollment Requests

Providers that are located outside of the Virginia border and require a site visit as part of the Affordable Care Act are required to have their screening to include the passing of a site visit previously completed by CMS or their State’s Medicaid program prior to enrollment in Virginia Medicaid. If your application is received prior to the completion of the site visit as required in the screening provisions of the Affordable Care Act (42 CFR 455 Subpart E) by the entities previously mentioned above, then the application will be rejected.

REVALIDATION REQUIREMENTS

All providers will be required to revalidate at least every 5 years. The revalidation of all existing providers will take place on an incremental basis and will be completed via the contracted MCO, MMP, the BHSA or DMAS. Providers will receive written instructions from the MCOs, MMPs, the BHSA or DMAS regarding the revalidation process, revalidation date and the provider screening requirements in the revalidation notice. If a provider is currently enrolled as a Medicare provider, the MCOs, MMPs, BHSA and DMAS may rely on the enrollment and screening facilitated by CMS to satisfy the provider screening requirements.

ORDERING, REFERRING AND PRESCRIBING (ORP) PROVIDERS

Code of Federal Regulations 455:410(b) states that State Medicaid agencies must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.

The ACA requires ordering, referring, and prescribing providers to enroll only to meet new ACA program integrity requirements designed to ensure all orders, prescriptions or referrals for items or services for Medicaid beneficiaries originate from appropriately licensed practitioners who have not been excluded from Medicare or Medicaid. The only exception to this requirement is if a physician is ordering or referring services for a Medicaid beneficiary in a risk-based managed care plan, the provider enrollment requirements are not applicable to that ordering or referring physician.

If a provider does not participate with Virginia Medicaid currently but may order, refer or prescribe to Medicaid members, the provider must now be enrolled to ensure claims will be paid to the servicing provider who is billing for the service.

As a servicing provider, it is essential to include the National Provider Identifier (NPI) of any ORP on all claims to ensure the timely adjudication of claims.

PARTICIPATION REQUIREMENTS

All providers enrolled in the Virginia Medicaid Program must adhere to the conditions of participation outlined in their Participation Agreements/contracts, provider contracts, manuals, and related state and federal regulations.  Providers approved for participation in the MCOs, MMPs and BHSA provider network must perform the following activities as well as any others specified by DMAS:

  • Immediately notify DMAS, the MCOs, MMPs and the BHSA in writing whenever there is a change in the information that the provider previously submitted. For a change of address, notify DMAS, the MCOs, MMPs and the BHSA prior to the change and include the effective date of the change; Once a health care entity has been enrolled as a provider, it shall maintain, and update periodically as DMAS, the MCOs, MMPs and the BHSA require, a current Provider Enrollment Agreement for each Medicaid service that the provider offers.
  • Use the MCOs, MMPs, BHSA and DMAS designated methods for submission of charges;
  • Assure freedom of choice to individuals in seeking medical care from any institution, pharmacy, or practitioner qualified to perform the service(s) required and participating in the Medicaid Program at the time the service is performed;
  • Assure the individual’s freedom to reject medical care and treatment;
  • Comply with Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. §§ 2000d through 2000d-4a), which requires that no person be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance on the grounds of race, color, or national origin;
  • Provide services, goods, and supplies to individuals in full compliance with the requirements of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), which states that no otherwise qualified individual with a disability shall, solely by reason of her or his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. The Act requires reasonable accommodations for certain persons with disabilities;
  • Provide services and supplies to individuals of the same quality and in the same mode of delivery as provided to the general public;
  • Charge the MCOs, MMPs, BHSA and DMAS for the provision of services and supplies to individuals in amounts not to exceed the provider’s usual and customary charges to the general public;
  • Not require, as a precondition for admission, any period of private pay or a deposit from the individual or any other party;
  • Accept as payment in full the amount reimbursed by DMAS. 42 CFR § 447.15 provides that a “State Plan must provide that the Medicaid agency must limit participation in the Medicaid Program to providers who accept, as payment in full, the amount paid by the agency”. The provider should not attempt to collect from the individual or the individual’s responsible relative(s) any amount that exceeds the usual Medicaid allowance for the service rendered. For example: If a third-party payer reimburses $5.00 of an $8.00 charge, and Medicaid’s allowance is $5.00, the provider may not attempt to collect the $3.00 difference from Medicaid, the individual, a spouse, or a responsible relative. The provider may not charge the MCOs, MMPs, BHSA, DMAS or an individual for broken or missed appointments;
  • Accept assignment of Medicare benefits for dual eligible Medicaid enrolled individuals;
  • Accept Medicaid payment from the first day of eligibility if the provider was aware that an application for Medicaid eligibility was pending at the time of admission;
  • Reimburse the individual or any other party for any monies contributed toward the individual’s care from the date of eligibility. The only exception is when an individual is spending down excess resources to meet eligibility requirements;
  • Maintain and retain business and professional records that document fully and accurately the nature, scope, and details of the health care provided; In general, such records must be retained for a period of at least five years from the date of service or as provided by applicable state laws, whichever period is longer. However, if an audit is initiated within the required retention period, the records must be retained until the audit is completed and every exception resolved;
  • Furnish to authorized state and federal personnel, in the form and manner requested, access to records and facilities;
  • Disclose, as requested by DMAS, all financial, beneficial, ownership, equity, surety, or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions, or other legal entities providing any form of health care services to Medicaid members; and
  • Hold information regarding Medicaid enrolled individuals confidential. A provider shall disclose information in his/her possession only when the information is used in conjunction with a claim for health benefits or the data is necessary for the functioning of the state agency. DMAS shall not disclose medical information to the public.
  • Obtain separate provider identification numbers for each physical or servicing location wanting to offer services to Virginia Medicaid members.

PROVIDER RESPONSIBILITIES TO IDENTIFY EXCLUDED INDIVIDUALS AND ENTITIES

In order to comply with federal regulations and Virginia Medicaid policy, providers are required to ensure that Medicaid is not paying for any items or services furnished, ordered, or prescribed by excluded individuals or entities. Medicaid payments cannot be made for items or services furnished, ordered, or prescribed by an excluded physician or other authorized person when the person or entity furnishing the services either knew or should have known about the exclusion. This provision applies even when the Medicaid payment itself is made to another provider, practitioner, or supplier that is not excluded, yet affiliated with an excluded provider. A provider who employs or contracts with an excluded person or entity for the provision of items or services reimbursable by Medicaid may be subject to overpayment liability as well as civil monetary penalties.

All providers are required to take the following three steps to ensure Federal and State program integrity:

  1. Screen all new and existing employees and contractors to determine whether any of them have been excluded.
  2. Search the HHS-OIG List of Excluded Individuals and Entities (LEIE) website monthly by name for employees, contractors and/or entities to validate their eligibility for Federal programs. See below for information on how to search the LEIE database.
  3. Immediately report to the contracted MCOs, MMPs and the BHSA any exclusion information discovered. Such information should also be sent in writing and should include the person or business name, provider identification number (if applicable), and what, if any, action has been taken to date. The information should be sent to:

DMAS

Attn: Program Integrity/Exclusions

600 E. Broad St, Suite 1300

Richmond, VA 23219

E-mail to: providerexclusions@dmas.virginia.gov

APPEALS

Individual’s Right to Appeal and Fair Hearing

The Code of Federal Regulations at 42 CFR §431 et seq., and the Virginia Administrative Code at 12VAC30-110-10 through 370, require that written notification be provided to individuals when DMAS or any of its contractors takes an action that affects the individual’s receipt of services. Most adverse actions may be appealed by the Medicaid client or by an authorized representative on behalf of the individual. Adverse actions include partial approvals, denials, reductions in service, suspensions, and terminations. Also, failure to act on a request for services within required timeframes may be appealed.  For individuals who do not understand English, a translation of appeal rights that can be understood by the individual must be provided.

 

If an appeal is filed before the effective date of the action, services may continue during the appeal process. However, if the agency's action is upheld by the hearing officer, the individual will be expected to repay DMAS for all services received during the appeal period. For this reason, the individual may choose not to receive continued services. The provider will be notified by DMAS to reinstate services if continuation of services is applicable.  If coverage is continued or reinstated due to an appeal, the provider may not terminate or reduce services until a decision is rendered by the hearing officer.

 

Appeals must be requested in writing and postmarked within 30 days of receipt of the notice of adverse action. The individual or his authorized representative may write a letter or complete an Appeal Request Form. Forms are available on the internet at www.dmas.virginia.gov, at the local department of social services, or by calling (804) 371-8488.

 

A copy of the notice or letter about the action should be included with the appeal request.

 

The appeal request must be signed and mailed to the:

Appeals Division

Department of Medical Assistance Services

600 E. Broad Street, 11th floor

Richmond, Virginia 23219

Appeal requests may also be faxed to: (804) 371-8491

 

The normal business hours of DMAS are from 8:00 a.m. through 5:00 p.m.  Documents received after 5:00 p.m. on the deadline date shall be untimely.

Provider Appeals of Adverse Actions

State-Operated Provider

The following procedures will be available to state-operated providers when DMAS takes adverse action which includes termination or suspension of the provider agreement or denial of payment for services rendered.  State-operated provider means a provider of Medicaid services that is enrolled in the Medicaid program and operated by the Commonwealth of Virginia.

 

A state-operated provider has the right to request a reconsideration of any issue that would be otherwise administratively appealable under the State Plan by a non-state operated provider.  This is the sole procedure available to state-operated providers.

 

The reconsideration process will consist of three phases: an informal review by the Division Director, a further review by the DMAS Agency Director, and a Secretarial review.  First, the state-operated provider must submit to the appropriate DMAS Division Director written information specifying the nature of the dispute and the relief sought.  This request must be received by DMAS within 30 calendar days after the provider receives a Notice of Program Reimbursement (NPR), notice of proposed action, findings letter, or other DMAS notice giving rise to a dispute.  If a reimbursement adjustment is sought, the written information must include the nature of the adjustment sought, the amount of the adjustment sought and the reason(s) for seeking the adjustment.  The Division Director or his/her designee will review this information, requesting additional information as necessary.  If either party so requests, an informal meeting may be arranged to discuss a resolution.

 

Any designee shall then recommend to the Division Director whether relief is appropriate in accordance with applicable laws and regulations.  The Division Director shall consider any recommendation of his/her designee and render a decision.

 

The second step permits a state-operated provider to request, within 30 days after receipt of the Division Director’s decision, that the DMAS Agency Director or his/her designee review the Decision of the Division Director.  The DMAS Agency Director has the authority to take whatever measures he/she deems appropriate to resolve the dispute.

 

 

The third step, where the preceding steps do not resolve the dispute to the satisfaction of the state-operated provider, permits the provider to request, within 30 days after receipt of the DMAS Agency Director’s Decision, that the DMAS Agency Director refer the matter to the Secretary of Health and Human Resources and any other Cabinet Secretary, as appropriate.  Any determination by such Secretary or Secretaries shall be final.

 

Provider Reconsiderations and Appeals (MCO and FFS)

Non-State Operated Provider

 

For services that have been rendered, providers have the right to appeal adverse actions.  However, before appealing to the Department, providers must first exhaust any MCO’s or DMAS Contractor’s reconsideration process.  Providers in an MCO’s network may not appeal enrollment or terminations decisions made by the MCO to the DMAS Appeals Division.  Providers enrolled with DMAS through the DMAS Contractor may appeal enrollment or termination decisions made by the DMAS Contractor to DMAS once they have exhausted the reconsideration process with the DMAS Contractor. 

 

Provider appeals to DMAS will be conducted in accordance with the requirements set forth in Virginia Code § 2.2-4000 et. seq. and 12 VAC 30-20-500 et. seq. 

 

All provider appeals to DMAS must be submitted in writing and within 30 calendar days of the provider’s receipt of the DMAS adverse action or the MCO’s or DMAS Contractor’s adverse reconsideration decision.  The provider’s notice of informal appeal is considered filed when it is date stamped by the DMAS Appeals Division.  The notice must identify the issues in the reconsideration decision being appealed.  Failure to file a written notice of informal appeal within 30 calendar days of receipt of the MCO’s or DMAS Contractor’s reconsideration decision shall result in an administrative dismissal of the appeal.  The notice of appeal must be transmitted to:

 

Appeals Division

Department of Medical Assistance Services

600 East Broad Street

Richmond, VA  23219

 

Appeal requests may be faxed to (804) 452-5454

 

The Department of Medical Assistance Services normal business hours are from 8:00 a.m. to 5:00 p.m. Eastern time. Any documentation or correspondence submitted to the DMAS Appeals Division after 5:00 p.m. shall be date stamped on the next day the Department is officially open. Any document that is filed with the DMAS Appeals Division after 5:00 p.m. on the deadline date shall be untimely.

 

Any provider appealing a DMAS informal appeal decision must file a written notice of formal appeal with the DMAS Appeals Division within 30 calendar days of the provider’s receipt of the DMAS informal appeal decision.  The notice of formal appeal must identify each adjustment, patient, service date, or other disputed matter that the provider is appealing.  Failure to file a written notice of formal appeal within 30 calendar days of receipt of the informal appeal decision shall result in dismissal of the appeal.   The notice of appeal must be transmitted to:

 

Appeals Division

Department of Medical Assistance Services

600 East Broad Street

Richmond, VA  23219

 

Appeal requests may be faxed to (804) 452-5454.

 

The provider may appeal the formal appeal decision to the appropriate circuit court in accordance with the Administrative Process Act at Va. Code § 2.2-4025, et. seq. and the Rules of Court.

 

The provider may not bill the member for covered services that have been provided and subsequently denied by DMAS.

EXHIBITS

 

Please use this link to search for DMAS Forms:

https://vamedicaid.dmas.virginia.gov/provider/forms

Provider Risk Category Table

Application

Rule Risk Category

App Fee Requirement

Yes (Y) or No (N)

Comprehensive Outpatient Rehab Facility (CORF)

Moderate

Y

Hospital

Limited

Y

Hospital Medical Surgery Mental Health and Mental Retarded

Limited

Y

Hospital Medical Surgery Mental Retarded

Limited

Y

Hospital TB

Limited

Y

Long Stay Hospital

Limited

Y

Long Stay Inpatient Hospital

Limited

Y

Private Mental Hospital(inpatient psych)

Limited

Y

Rehab Outpatient

Limited

Y

Rehabilitation Hospital

Limited

Y

Rehabilitation Hospital

Limited

Y

State Mental Hospital(Aged)

Limited

Y

State Mental Hospital(less than age 21)

Limited

Y

State Mental Hospital(Med-Surg)

Limited

Y

Audiologist

Limited

N

Baby Care

Limited

N

Certified Professional Midwife

Limited

N

Chiropractor

Limited

N

Clinical Nurse Specialist - Psychiatric Only

Limited

N

Clinical Psychologist

Limited

N

Licensed Clinical Social Worker

Limited

N

Licensed Marriage and Family Therapist

Limited

N

Licensed Professional Counselor

Limited

N

Licensed School Psychologist

Limited

N

Nurse Practitioner

Limited

N

Optician

Limited

N

Optometrist

Limited

N

Physician

Limited

N

Physician

Limited

N

Physician

Limited

N

Podiatrist

Limited

N

Psychiatrist

Limited

N

Psychiatrist

Limited

N

Substance Abuse Practitioner

Limited

N

Ambulance

Moderate

Y

Ambulance

Moderate

Y

Durable Medical Equipment (DME)

Moderate - Revalidating

High - Newly Enrolling

Y

Emergency Air Ambulance

Moderate

Y

Emergency Air Ambulance

Moderate

Y

Hearing Aid

Limited

N

Home Health Agency - State Owned

Moderate - Revalidating

High - Newly Enrolling

Y

Home Health Agency - Private Owned

Moderate - Revalidating

High - Newly Enrolling

Y

Hospice

Moderate

Y

Independent Laboratory

Moderate

Y

Local Education Agency

Limited

N

Pharmacy

Limited

N

Prosthetic Services

Moderate - Revalidating

High - Newly Enrolling

Y

Renal Unit

Limited

Y

Adult Day Health Care

Limited

N

Private Duty Nursing

Limited

N

Federally Qualified Health Center

Limited

Y

Health Department Clinic

Limited

N

Rural Health Clinic

Limited

Y

Developmental Disability Waiver

Limited

N

Alzheimer’s Assisted Living Waiver

Limited

N

Treatment Foster Care Program

Limited

N

Qualified Medicare Beneficiary (QMB)

Limited

N

ICF-Mental Health

Limited

Y

ICF-MR Community Owned

Limited

Y

ICF-MR State Owned

Limited

Y

Intensive Care Facility

Limited

Y

Skilled Nursing Home

Limited

Y

SNF-Mental Health

Limited

Y

SNF-MR

Limited

Y

Psych Residential Inpatient Facility

Limited

Y

Consumer Directed Service Coordination

Limited

N

Personal Care

Limited

N

Respite Care

Limited

N

Personal Emergency Response System

Moderate - Revalidating

High - Newly Enrolling

Y

Case Management DD Waiver

Limited

N

CMHP Transition Coordinator

Limited

N

Transition Coordinator

Limited

N

PACE

Limited

N

Family Caregiver Training

Limited

N

Mental Retardation Waiver

Limited

N

Mental Health Services

Moderate - Revalidating

High - Newly Enrolling

Y - only for Mental Health Clinics

Early Intervention

Limited

N

Group Enrollment

Limited

N

Group Enrollment

Limited

N

Ambulatory Surgical Center

Limited

Y

Ordering, Referring, or Prescribing Provider

Limited

N