Print
Skip left navigation

Chapter 5: Early, Periodic Screening, Diagnosis and Treatment (EPSDT)/Prevention

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children younger than age 21 who are enrolled in Medicaid.

Follow the EPSDT schedule for all eligible UnitedHealthcare Community Plan members to age 21, including pregnant women. EPSDT screening includes immunizations, hearing, vision, speech screening and nutritional assessments; dental screening; and growth and development tracking.

For complete details about diagnoses codes as well as full and partial screening, examination, and immunization requirements, go to the EPSDT schedule.

To find the Healthy Child Forms, go to: medquest.hawaii. gov/en/resources/forms.html.

Find details on how to fill out the Healthy Child form at: medquest.hawaii.gov/en/resources/forms.html.

Developmental disabilities are severe and chronic disabilities due to a mental or physical impairment that begins before the member reaches adulthood. These disabilities include intellectual disability, cerebral palsy, epilepsy, autism, and disabling conditions related to intellectual disability or requiring similar treatment. The Department of Developmental Services (DDS) is responsible for a system of diagnosis, counseling, case management, and community support of persons with intellectual disability, cerebral palsy, epilepsy, and autism for children older than 36 months to adulthood.

Referral – If you determine supportive services would benefit the member, refer the member to DDS for approval and assignment of a Regional Center Case Manager who is responsible for scheduling an intake assessment. Determination of eligibility is the responsibility of the Regional Center Interdisciplinary Team. While the Regional Center does not provide overall case management for their clients, they must assure access to health, developmental, social, and educational services from birth throughout the lifespan of individual who has a developmental disability.

Continuity of Care – The Regional Center will determine the most appropriate setting for eligible HCBS services and will coordinate these services for the member in collaboration with the PCP and health plan coordinator. The Care Coordinator and PCP continue to provide and manage primary care and medically necessary services. If the member does not meet criteria for the program or placement is not currently available, UnitedHealthcare will continue care coordination as needed to support the member’s screening, preventive, medically necessary, and therapeutic covered services.

The Early Start Program provides early intervention services to infants and toddlers with disabilities and their families.

Referral – refer children who are identified as potentially requiring developmental intervention services to the appropriate agency for evaluation once you identified the need for services. Provide information as requested to complete the referral process. If the child has a visual impairment, hearing impairment, or severe orthopedic impairment, or any combination of these impairments, contact the Department of Health Early Intervention Program (DOHEIP) for evaluation and early intervention services. A service coordinator will be assigned to help the child’s parents through the process to determine eligibility.

Continuity of Care – support the development of the Individualized Family Service Plan (IFSP) developed by the Early Start Program through the DOHEIP. UnitedHealthcare Community Plan provides member case management and care coordination to help ensure all medically necessary covered diagnostic, preventive and treatment services are identified in the IFSP developed by the Early Start Program, with your participation.

Contact the DOHEIP referral line at 808-594-0066 for Oahu or 800-235-5477 for Neighbor Islands. To make a referral by fax, please download the EI referral form and instructions.

Perform a full screen. Include:

  • Interval history
  • Unclothed physical examination
  • Anticipatory guidance
  • Lab/immunizations (Lab and administration of immunizations is reimbursed separately.)
  • Lead assessment (Use the Lead Risk Assessment form.)
  • Personal-social and language skills
  • Fine motor/gross motor skills
  • Hearing
  • Vision
  • Dental

Without all these age appropriate components, you cannot bill for a full screen. You may only bill for a partial screen.

Interperiodic Screens are medically necessary screens outside the standard schedule that do not require the full screen. Use this screen to start expanded HCY services. Office visits and full or partial screenings happening on the same day by the same care provider are not covered unless medical necessity is noted in the member’s record.

Interperiodic Screens are often used for school and athletic physicals. A physical exam may be needed for a certificate stating a child is physically able to take part in school athletics. This also applies for other school physicals when required as conditions for educational purposes.

Call Provider Services if you find a child has a lead blood level over 10ug/dL. Children with elevated blood lead levels will be offered enrollment in a care coordination program.

Medicaid covers Sexual Assault Findings Examination (SAFE) and Child Abuse Resource Education (CARE) Examinations. It also covers related laboratory studies that determine sexual or physical abuse. The exam is performed by SAFE-trained providers certified by the Department of Health and Senior Services. Children enrolled in a managed health care plan receive SAFE- CARE services through Hawaii Medicaid on a fee-for- service basis. Call Hawaii Medicaid for more information.

Oahu

Kapiolani Medical Center for Women & Children, The Sex Abuse Treatment Center 808-524-7273 (24-hour hotline)

Kauai

YWCA of Kauai, Sexual Abuse Treatment Program

808-245-4144 (24-hour hotline)

Maui

Child and Family Service, Maui Sexual Assault Center

808-873-8624 (24-hour hotline)

Hawaii Island

YWCA of Hawaii Island, Sexual Assault Support Services

808-935-0677 (24-hour hotline)

Visit ag.hawaii.gov for more information.

Targeted Case Management (TCM) consists of case management services for specified targeted groups to access medical, social, educational, and other services provided by a Regional Center or local governmental health program as appropriate.

Identification – The five target populations include:

  • Children under the age of 21 at risk for medical compromise
  • Medically fragile individuals
  • Individuals in frail health, over the age of 18 and at risk of institutionalization
  • Members in jeopardy of negative health or psychosocial outcomes
  • Members infected with a communicable disease, including tuberculosis, HIV/AIDS, etc., or who have been exposed to communicable diseases, until the risk of exposure has passed

Referral – Members who are eligible for TCM services are referred to a Regional Center or local governmental health program as appropriate for the provision of TCM services.

Continuity of Care – UnitedHealthcare Community Plan is responsible for coordinating the member’s health care with the TCM provider and for determining the Medical Necessity of diagnostic and treatment services recommended by the TCM provider that are covered services under the contract.

The Vaccines for Children program provides immunizations. Immunizations offered in the state VFC program must be ordered by your office. We do not reimburse for the vaccine ordered by the VFC Program, but we reimburse for administering the vaccine.

Vaccine administration fees are reimbursable when submitted with an appropriate CPT and modifier code. We cannot reimburse for private stock vaccines when they are available through VFC.

Any child through 19 years of age who meets at least one of the following criteria is eligible for the VFC Program:

  • Eligible for Medicaid.
  • American Indian or Alaska Native, as defined by the Indian Health Services Act.
  • Uninsured.
  • Underinsured (these children have health insurance but the benefit plan does not cover immunizations.

Children in this category may receive their vaccinations from a federally qualified health center, rural health clinic, or a private health care provider using a VFC supplied vaccine.

Contact VFC with questions

Contact VFC with questions.

Phone: 808-586-8300

Fax: 573-526-5220