Reminder: VitalCare for Kids (EPSDT)

MaineCare’s VitalCare for Kids (EPSDT) program allows members under the age of 21 to receive medically necessary services that are not typically covered due to limits on the type, frequency, or duration of the service. The program is designed to ensure children and youth receive early detection and care, so health problems are prevented or diagnosed and treated as early as possible.

When a PA request for a member under age 21 cannot be approved under normal MaineCare policy limits, further review is conducted to determine if the service meets the VitalCare for Kids requirements. If so, service limits can be exceeded, and the service can be approved under the VitalCare for Kids program. Program service requirements are listed on the VitalCare for Kids webpage.

If a PA request for a member under 21 has been denied and you feel it has been denied without VitalCare for Kids being taken into consideration, please email Provider Services or call 1-866-690-5585.

Billing for Services Approved Under VitalCare for Kids:  

When services are approved under VitalCare for Kids, providers MUST flag the claim appropriately to indicate it is EPSDT related AND, for CMS 1500 and UB 04 forms, amend the “EP” modifier to the approved service code. Please follow the billing instructions below for specific claim forms. 

CMS 1500 Billing Instructions  

  • Box 24H, EPSDT Family Plan: Enter a “Y” if a service is approved under EPSDT.   

AND

  • 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.  

AND

  • 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.   

AND

  • Box 24, Procedure Date: Enter procedure date if “EPSDT/Title XIX” is marked in Box   

For more information regarding VitalCare for Kids service billing, please see MaineCare's Billing Instructions or contact your MaineCare Provider Relations Specialist. 

For further information about accessing VitalCare for Kids, please visit MaineCare’s VitalCare for Kids webpage or contact the VitalCare for Kids Program Coordinator, at DHHS.EPSDT@maine.gov.