General principles of medical record ... - Freedom Health

Dear Provider, 

As you know, Medicaid Health Plans in FL submit an annual Child Health Check-up (CHCUP) Report to the 

Agency for Health Care Administration (AHCA); related to their performance in the CHCUP program. The 

State establishes performance thresholds for Plan’s CHCUP screening and participation rates, and it is the 

State’s expectation that Freedom Health meets, or exceeds, these thresholds. Plans not meeting the performance 

thresholds are required to initiate corrective action plans (CAP’s), and are also subject to sanctions levied by the 

State; per Medicaid Core Contract, Section XIV. 

Freedom Health wants to work with our providers to ensure that we adhere to the Medicaid CHCUP program, 

and provide regular health check-ups for children/adolescents that include: 

x Comprehensive health and developmental history (include assessment of behavioral health status); 

x Comprehensive unclothed physical exam; 

x Nutritional and developmental assessment; 

x Vision, hearing and dental screenings; 

x Lab tests (including blood test for lead poisoning); 

x Immunizations; as appropriate 

x Diagnosis and treatment; health education/anticipatory guidance; 

x Referral and follow-up, as needed. (Referrals dentists begin at 3 yrs or earlier, as medically necessary) 

Eligible children and adolescents should have a child health check-up at the following ages: 

At birth; 2-4 days for newborns 1 month 2 months Annually for ages 2-20 

4 months 6 months 9 months 

12 months 15 months 18 months 

Freedom is working to increase our CHCUP screening and participation rates. As part of our commitment to 

providing better care for our members, we offer additional reimbursement to providers who perform 

CHCUP services, and bill appropriately. Please refer to the compensation page of your contract, or speak with 

your MSO/IPA for additional information. It is our expectation that providers follow compliant billingpractices, 

when submitting claims for CHCUP. This allows us to systematically identify all CHCUP services 

provided to our members. Freedom’s failure to identify CHCUP services; could result in fines and/or sanctions 

from the State. Therefore, we will conduct a thorough review of our CHCUP program to identify processes 

which could result in under-reporting. We are asking provider offices to assess their documentation and billing 

practices for CHCUP’s. Freedom may consider the re-assignment of members, or amendments to contract 

reimbursement; with penalty levels, for non-compliance with the state requirements for CHCUP. Please see 

attached CHCUP tools; designed to aid our providers with CHCUP compliance. We want to help you identify 

any processes which could impact CHCUP claim submission, and ensure that a corrective resolve is enabled. 

For more information, please contact your Freedom Provider Operations Representative or call our office at 

(305) 751-0891. We look forward to working with you in providing care for our members. 

Yours Sincerely, 

Christopher J. O’Connor 

Senior V.P. of Operations 

Periodic CHCUP services help identify and correct medical conditions in Children/Adolescents. 

Last Updated: 8.11.2011

Freedom Health Child Health Check-Up Medical Record Compliance Tool 

A CHCUP service should include all of the following components, referenced below, and documented in the 

medical record. A CHCUP should not reflect a sick visit, unless an initial or periodic screen was performed 

during the visit. CHCUP screens can be performed outside of the State’s periodicity schedule if it is a “catchup” 

screen; to bring the child up-to-date with the periodicity schedule. 

Please use these tools to assess your office’s CHCUP documentation practices, and also billing processes, 

related to child health check-ups performed in your office. 

Comprehensive Health & Developmental History; on every CHCUP visit Documented 

Updated History Yes ɷ No ɷ 

Allergies: Allergies documented in the medical record. 

Yes ɷ No ɷ 

Unclothed Physical Exam Yes ɷ No ɷ 

Developmental Assessment Yes ɷ No ɷ 

Behavioral Health Assessment Yes ɷ No ɷ 

Nutritional Assessment: A detailed age-appropriate nutritional assessment done, e.g. Yes ɷ No ɷ 

type of formula, # of feedings per day, assessment of food groups, etc 

Growth: Height, weight, BMI, and head circumference measured, plotted on graph Yes ɷ No ɷ 

Anticipatory Guidance: Age appropriate health education and counseling at every 

CHCU, documented in the MR. Provider may use oral or written information. 

Yes ɷ No ɷ 

Immunizations: Up-to-date; for age, according to recommended Immunization Schedule Yes ɷ No ɷ 

Lab Testing 

Blood Lead Screening: Lead screening as required. CPT code for lead testing: 83655 Yes ɷ No ɷ 

Abnormal Blood Lead Labs: Appropriate follow-up for children with abnormal 

Yes ɷ No ɷ 

blood lead values. 

Screenings 

Dental Screening: Including a direct referral to a dentist for children, starting at 

age 3, or earlier as indicated 

Vision Screening: Objective testing; diagnosis and treatment as required 

Hearing Screening: Objective testing; diagnosis and treatment as required 

Referrals: Referral and appropriate follow-up between PCP and specialist documented. 

Yes ɷ No ɷ 

Yes ɷ No ɷ 

Yes ɷ No ɷ 

Yes ɷ No ɷ 

Billing includes CHCUP Referral Codes: Yes ɷ No ɷ 

Box24H on CMS1500 form, FB0-22.0 on NSF Format, Loop 2300, Segment CRC; 

EPSDT Referral, on X12N 837P format, and Claim Information Tab, EPSDT Info 

button – Check “Yes” for Condition Indicator (WINASAP 2003, Professional Claim) 



Freedom Health Child Health Check Up (CHCUP) Billing Compliance Tool 

Eligibility - Medicaid members are eligible for CHCUP services until their 21st birthday. Providers should bill 

for CHCUP’s on a physician claim form; using appropriate codes and modifiers. CHCUP claims can only be 

billed in the following formats: CMS1500l. 

New Patient - Initial evaluation and mgt of a healthy individual requiring a comprehensive history, a 

examination, identification of risk factors, and ordering of appropriate lab/diagnostic procedures 

99381 Infant (age under 1 year) 

99382 Age 1 through 4 years 



99385 Age 18 through 20 years -- use EP modifier 

Established Patient - Periodic re-evaluation and mgt of a healthy individual requiring a comprehensive history, 

examination, identification of risk factors and the ordering of appropriate lab/diagnostic procedures 

99391 Infant (age under 1 year) 




99395 Age 18 through 20 years -- use EP modifier 

Newborn Care - Services to newborns, incl physical examination, initiation of diagnostic and/or treatment and 

preparation of medical records for the infant. Note: CPT code changes for newborn screens 

99460 (old: 99431) Newborn Care - History and Examination (replaces code 99431) 

99461 (old: 99432) Normal Newborn Care (replaces code 99432) 

99463 (old: 99435) Newborn Care (history and examination) (Replaces code 99435) 

Referral Codes: It is a federal requirement that referral codes are billed for CHCUP services, if a member was 

scheduled for a follow-up appointment for specialized treatment services; as a result of a health problem 

identified during a CHCUP screening service. 

V Patient Refused Referral. 

U 

Patient Not Referred; when exam is normal, and no referrals made 

2 Abnormal, Treatment Initiated; when a child is currently under treatment for 

referred diagnostic or corrective health problem. 

T 

Abnormal, Child Referred for New Services; when patient is referred for new 



diagnostic or corrective treatments; not including dental referrals 

Mandatory CMS-1500 fields for ‘clean’ claim submission 

(to be completed by the provider.) 

If mandatory claim elements are missing, invalid, or incomplete, this will cause your claim to be rejected. 

Rejected claims will be returned to the provider, with a request for re-submission of the ‘missing’ data 

elements. 

Mandatory Field 

Description 

1A. Insured I.D number – Mandatory 

2. Patients Name - Mandatory 

3. *The Patient’s date of birth and sex. - Mandatory 

4. *Insured’s name - Mandatory 

5. *Patient’s address – Mandatory 

6. *Patient’s relationship to insured - Mandatory 

7. *Insured’s address – If different from patient’s address 

10. Patients condition related to employment, auto accident, and other accident - Mandatory 

11d. *is there another health benefit plan? – Mandatory 

21. Diagnosis codes - mandatory 

24a.Date of service – mandatory 

24b.Place of service code – mandatory 

24d. CPT/HCPCS – mandatory 

24E.*Diagnosis pointer – mandatory (if not specified, all dx codes will be pointed to all the CPT codes billed on 

the CMS1500) 

24F. Charges – mandatory 

24G. Units – mandatory (if not specified, it will be defaulted to 1) 

24H. Referral Code (EPSDT Family Plan); mandatory for CHCUP services 

24J. Rendering provider id (NPI) - mandatory 

25. Federal Tax ID number - mandatory 

28. Total charges - mandatory 

30. Balance due – mandatory if different from Total Charges 

31. Signature of physician or supplier – mandatory 

32. Service facility location information – mandatory on ambulance claims 

33. Billing Provider’s info – mandatory 

33a. billing provider’s NPI# - mandatory

General principles of medical record ... - Freedom Health

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