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

Healthchek is Ohio’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. It 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.

The UnitedHealthcare Community Plan pediatric service requirements includes Healthchek screenings for children up to age 21. The PCP is responsible for complying with and coordinating services related to Healthchek.

It is essential that children enrolled in UnitedHealthcare Community Plan receive screening exams at the appropriate ages. The PCP member roster identifies those members who are due for a Healthchek screen in the upcoming month. UnitedHealthcare Community Plan will assist the PCP in notifying members due for a Healthchek screen. The PCP is also responsible for Healthchek outreach and follow-up care.

Learn more at medicaid.ohio.gov > For Ohioans > Programs > Children and Families > Healthchek.

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.

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. Ohio law requires all health care providers to administer blood lead test to children at age 1 and 2 years, or up to age 6 if no previous test has been completed. PCPs must use a participating lab service  for collection. PCPs may draw the blood in the office and use the selected lab’s courier service if available. Direct the member to the selected lab’s nearest draw site.

During the Healthchek screening, PCPs should identify the need for other medically necessary services.

Children younger than 21 years old may receive other medically necessary services, including speech therapy, occupational therapy, physical therapy, nutritional counseling, specialized nursing care, behavioral health, psychological services and mental health wrap-around services. Submit requests for these services to the Utilization Management department.

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 Ohio Medicaid on a fee-for- service basis. Call Ohio Medicaid 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 Adult Care Management portion of the program identifies and risk-stratifies the adult medically complex population with consideration to co-morbid conditions and social environment. Activities are designed to address members within the continuum of their disease, including educational outreach, ongoing- targeted short and long-term care management, as well as collaboration with the member’s provider and other health care team members to effectively educate and develop an optimal treatment plan to help the member manage their disease.

The Pediatric Care Management portion of the program was intentionally designed to have a very broad diagnoses base to allow referrals for reasons other than catastrophic type illnesses or conditions.

Disease Management Programs Offered Through UnitedHealthcare Community Plan:

Asthma Care Management

Each patient is assessed, stratified and the care plan intensity can range from basic education mailings for those members who require limited assistance to comprehensive care plans with frequent outreach, including face-to-face visits for high-risk members and their treating providers.

All children younger than 21 years with a diagnosis of asthma, regardless of severity, should be referred to care management services for screening/assessment.

High-Risk Pregnancy Care Management

The High-Risk Pregnancy program is through the Healthy First Steps program, which offers coaching for all pregnant members to encourage pre-natal care.

Members are identified as high-risk, primarily through the OB/GYN physician’s submission of the Prenatal Risk Assessment Form that is completed during the first prenatal visit. The assessment form is designed to clearly identify members who are at risk of pre-term labor or a poor outcome of the pregnancy.

High-risk pregnancy indicators are as follows:

  • Teen pregnancy – age 17 and younger (CSHCN indicator).
  • Pre-term labor.
  • Premature rupture of membranes/cervical dilation.
  • Uncontrolled insulin dependent diabetes.
  • Fetal anomalies.
  • Placental/uterine abnormalities.
  • Hyper-emesis.
  • Incompetent cervix.
  • Uncontrolled asthma.
  • Uncontrolled or chronic hypertension/pregnancy induced.
  • Hypertension.
  • Pre-eclampsia.
  • Multiple gestation.
  • History of 3 or more previous miscarriages after first trimester.
  • Bleeding after first trimester.
  • Current drug or alcohol abuse.

Diabetes Care Management

Diabetes care management focus is education and improved compliance with the provider’s treatment plan. Patients are primarily identified through claims and pharmacy activity but as with all of the programs, members, treating providers and the plan’s Utilization Management department are also a strong referral source. Each member is assessed, stratified and the care plan is customized to meet each member’s needs. Members that require limited assistance will receive educational mailings and members who require a more intense approach, a comprehensive care plan will be developed that includes frequent outreach to both the member and the treating provider.

Transplant Care Management

The Transplant Care Management program monitors the member from initial evaluation throughout the transplant hospitalization. After the transplantation has occurred, the member is followed by the health plan’s care managers. Activities are designed to address members within the continuum of care, provide ongoing-targeted care management, which includes collaboration with the member’s providers and the facility transplant team.

The transplant care managers are assigned as the member enters the transplant evaluation process. The care manager performs the UM activities associated with the transplant evaluation, all inpatient admissions and related outpatient services. The care manager develops a relationship with the patient, family and the hospital transplant team, which allows the care manager to support the patient and family through a very difficult and stressful time of their lives.

The Vaccines for Children (VFC) 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 18 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 not only receive vaccinations from a federally qualified health center or rural health clinic; they cannot receive vaccinations from 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