Appendix A Well Child Check-Up (EPSDT)

Well Child Check-Up
NOTE:
Once benefit limitations have been exceeded, Medicaid will not pay for
services without the EPSDT referral. This is important for patients with
chronic conditions or a problem that will require numerous visits to treat.
Providers should write the referral as soon as the condition is noted so that
the regular benefits are not exhausted.
The referral form should follow the recipient for all services related to the
condition noted on the form. If a child is screened with a particular condition
noted and referred for further diagnosis, and another condition develops that is
not noted on the referral form, the child must be re-screened in order to receive
expanded benefits for the second condition noted. If not re-screened, the
services rendered would count against the child's routine benefit limits.
NOTE:
If the screening provider refers a child to a consultant, it is the screening
provider’s responsibility to follow up. However, if the managed care provider
refers the child to a consultant, it is the managed care provider’s
responsibility to follow up.
A.4.5
EPSDT Referrals for Patient 1st Recipients
Scenario: A child is referred by the PMP to be screened by a county health
department and appears to have a foot deformity.
Procedure: The child must be sent to their assigned Primary Medical Provider
(PMP) to obtain the PMP referral form. The PMP may choose to
• Provide the necessary treatment
• Refer the child to an orthopedic specialist
• Instruct the screening provider to complete the referral form
The PMP must complete the Alabama Medicaid Agency Referral Form (Form
362) if referring the child to a specialist. The name and address of the screening
provider should be entered to reflect, in this scenario, the county health
department. The screening NPI and signature will reflect the county health
department number and the signature of the health department employee who
performed the screening.
The referring/PMP number reflects the NPI of the PMP. The consulting provider
must use the PMP’s number as the referring physician on the claim form.
In this scenario, the specialist may suggest surgery, braces, and/or therapy. All
services approved by and referred by the PMP would then be covered by an
EPSDT screening referral.
A-34 January 2011