Appendix A Well Child Check-Up (EPSDT)

Well Child Check-Up
• A primary care referral list of medical providers in the county to whom you
will refer to services. The referral list must include pediatricians, family and/or
general practice physicians, internal medicine physicians, vision and hearing
providers, and dentists. All providers must agree to be on your referral list,
therefore, you must submit their written agreement with your referral list. The
list must be sufficient in number to allow recipients/parents a choice in the
selection of a provider.
• Documentation to demonstrate that services will be offered to all children
enrolled at an off-site location, not just Medicaid-eligible children. A copy of
your fee schedule must be attached to your documentation and must include
fees for non-Medicaid enrollees.
• Child abuse and confidentiality policies
• A signed Matrix of Responsibilities form between the off-site location
authority (school superintendent, principal, day care director, etc.) and the
screening provider. Only one screening provider will be approved per
location.
NOTE:
Only RNs that are employed by a FQHC, RHC, Health Department,
Physicians office, and hospital may perform off-site EPSDT screenings.
• A signed agreement/letter from a local physician to serve as Medical
Director. This physician may be a pediatrician, family practice physician,
general practice physician, or an internal medicine physician. Proof of 6
pediatric focused credits (CME) from the previous year must be included with
the signed agreement. EXCEPTION: A board-certified pediatrician should
submit a copy of current certification only. The medical director is
responsible for resolving problems that the nurses encounter and
rendering care for medical emergencies.
• A monthly schedule shall be maintained designating the dates, times, and
the local agency in which you will be offering the EPSDT services. The
monthly schedule should be readily available and retained in either the local
agency/medical facility (i.e., the facility that has been approved as an off-site
EPSDT screening provider) or the recipient’s medical record. Failure to
maintain schedules one week in advance of Off-site EPSDT screenings may
result in termination and loss of revenue.
• A document, listing members of the Peer Review Coalition of community
members to serve in an advisory capacity. The committee must have the
opportunity to participate in policy development and program administration
of the provider’s off-site program and to advise the director about health and
medical service needs within the community. The committee must be
comprised of parents, school personnel, public health personnel and local
physicians within the local community. Members must be familiar with the
medical needs of low-income population groups and with the resources
available in the community.
A-40 January 2011