The goal of the EPSDT program is to ensure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.
What is EPSDT?
EPSDT is a program which allows MaineCare members under the age of 21 to receive services that are not typically covered due to limits on the type, frequency, or duration of the service. These services can include preventive, dental, developmental, behavioral health, and specialty services.
For example, MaineCare’s dental benefit covers one crown per tooth per five years, but if the service meets the EPSDT criteria and is approved as an EPSDT service, children, and youth under 21 can exceed this limit.
National Standards of Care
Under EPSDT, federal regulations state that MaineCare is required to adopt national standards of care.
MaineCare has adopted and encourages providers to use the American Academy of Pediatrics (AAP) Bright Futures Guidelines including the Bright Futures/AAP Periodicity Schedule and MaineCare’s Recommendations for Preventive Pediatric Oral Health Care when evaluating children and youth up to 21 years of age.
Getting a Service Approved through EPSDT
The MaineCare Benefits Manual, Chapter II, Section 94 states that for treatment services to be approved under the EPSDT program, services must comply with several requirements. Please see the first five accordions in reference to getting a service approved through EPSDT. The remaining accordions include various provider resources.
- EPSDT Service Requirements
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The service must:
A. be documented scientifically with valid clinical evidence of effectiveness;
B. not be considered investigational or experimental;
C. be the most cost-effective service that would provide the member with the same medically necessary outcome and intended purpose;
D. be prior authorized by the Prior Authorization (PA) Unit of MaineCare Services. Requests for PA of Durable Medical Equipment will be reviewed by an authorized agent of the Department;
E. be medically necessary as defined in Chapter I, Section 1.02 (D), “General Administrative Policies and Procedures”, of the MBM;
F. not be custodial, academic, educational, vocational, recreational or social in nature as described in Chapter I, Section 1.02 (D);
G. not be respite care, which is defined as services given to individuals unable to care for themselves that are provided on a short-term basis because of the absence or need for relief of those persons normally providing the care.
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Prior Authorization (PA) Required
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Providers must submit a PA request for services to be considered for coverage under the EPSDT program. Providers should complete PAs with as much detail as possible to explain the plan of care, including:
The conditions that the plan addresses.
The services needed to address the conditions and why those services meet medical necessity.
The providers who will provide the needed services.
- Meeting Medical Necessity
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Health care providers need to provide documentation of medical necessity, including:
Supporting medical records.
Other services that have been tried, if any.
Explanation for why the services are of a type, frequency or duration not otherwise covered by MaineCare.
Explanation for why services covered in the MaineCare Benefits Manual are insufficient or inappropriate.
Supporting medical literature which demonstrates that the proposed services will be effective.
- Requesting an EPSDT PA
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For services that are NOT behavioral/mental health services:
PA requests can be submitted through the MaineCare HealthPAS Online Portal. The Health PAS Online Portal is where providers submit claims, PAs, and update their information. If you have questions about submitting a PA request through the online portal, you can contact your MaineCare Provider Relations Specialist.
If you are a MaineCare enrolled provider and do not have access to the HealthPAS Online Portal, please visit the HealthPAS registration page to gain access through your Trading Partner Account (TPA). For questions regarding the registration process, please contact Gainwell Technologies at 1-866-690-5585 or by email.
For services that ARE behavioral health services:
Behavioral health authorizations are processed through Acentra Health. The provider should submit supplemental information supporting the medical necessity of the service to Acentra with the referral or request, through the Atrezzo portal. For instructions on how to submit authorization requests through the portal please visit Acentra’s training webpage.
For questions specific to the Acentra authorization process or the Atrezzo Portal, please contact Acentra Provider Relations at 866-521-0027, Option 3 or by email.
For durable medical equipment (DME):
Treating providers must send the prescription, clinical notes pertaining to the item prescribed, and a letter of medical necessity to a MaineCare enrolled DME provider. The DME provider then submits a PA request to MaineCare with the appropriate supporting documents.
Please note: It is highly recommended to submit a PA request electronically through the
HealthPAS Online Portal. Faxing is NOT recommended.
However, if faxing is the necessary method, please follow the instructions on the Faxing an EPSDT Prior Authorization Request document.
- Billing for Services Approved Under EPSDT
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Please see the tables below for specific claim form instructions.
CMS 1500 Billing Instructions
Box 24H, EPSDT Family Plan
Enter a “Y” if a service is approved under EPSDT.
HCPCS/RATES/HIPPS Code
Use the appropriate “EP” modifier, along with the procedure code approved under EPSDT.
UB 04 Billing Instructions
FL 18 – 28, Condition Codes
Enter code “A1” into one of the condition code boxes.
FL 44, HCPCS/RATES/HIPPS Codes
Use the appropriate “EP” modifier, along with the procedure code approved under EPSDT.
Dental Services Billing Instructions
Box 1, Type of Transaction
Enter an “X” in the box next to the EPSDT option for services approved under EPSDT.
Box 24, Procedure Date
Enter procedure date if “EPSDT/Title XIX” is marked in Box 1.
For more information regarding EPSDT service billing, please see MaineCare's Billing Instructions Guides or contact your MaineCare Provider Relations Specialist.
- Provider Education
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- EPSDT Learning Module; MaineCare in Education 104: EPSDT for Children and Youth – This is a new learning module for providers, located on the MaineCare in Education web page
- EPSDT Provider Fact Sheet - A one-page overview of the EPSDT program for providers and staff.
- Screening Tools
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- EPSDT Preventative Health Screening Tools (PDF) - This document provides a list of screening tools health providers can use in conjunction with the AAP Bright Futures Guidelines for well-child visits.
- Autism Toolkit – Caring for Children with Autism Spectrum Disorders – A resource toolkit for clinicians.
- MaineCare's Bright Futures Health Assessment Visit Forms
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- First Weeks (PDF)
- One Month (PDF)
- Two Months (PDF)
- Four Months (PDF)
- Six Months (PDF)
- Nine Months (PDF)
- Twelve Months (PDF)
- Fifteen Months (PDF)
- Eighteen Months (PDF)
- Two Years (PDF)
- Two and a Half Years (PDF)
- Three Years (PDF)
- Four Years (PDF)
- Five to Six Years (PDF)
- Seven to Eight Years (PDF)
- Nine to Ten Years (PDF)
- Eleven to Fourteen Years (PDF)
- Fifteen to Twenty-One Years (PDF)
- Letter Templates
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- Additional Resources
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- Common Pediatric Preventative Services for Providers (PDF) - This document is intended for providers and lists common codes and other information regarding pediatric preventive services.
- Maine Immunization Program
Questions
For further information or questions about EPSDT, please contact Becky Parsons, EPSDT Program Coordinator, at DHHS.EPSDT@maine.gov.