Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents under age 21 in low-income families and includes a broad selection of preventive, diagnostic and treatment services. EPSDT ensures that Medicaid beneficiaries under age 21 have access to the health care they need when they need it and covers most health services needed to stay as healthy as possible.
EPSDT ensures that eligible children and young adults can receive preventive services; early care and acute care; and ongoing long-term treatment and services to prevent, diagnose and treat health problems as early as possible. EPSDT addresses potential or existing health problems before they begin or before they become advanced and life-limiting and treatment becomes more complex and costly. It often offers coverage without many of the restrictions in overall Medicaid or a Medicaid waiver for this age group.
EPSDT preventive services (early and periodic screens/wellness visits) will not require prior authorization from ACNC. Prior authorization may be required for other EPSDT diagnostic and treatment products. Use our Prior Authorization Lookup tool for immediate guidance on prior authorization requirements.
Watch Video: EPSDT Orientation for AmeriHealth Caritas North Carolina (ACNC) Providers
The total running time of this Zoom video training is about 18 minutes. Please complete the attestation survey. Additional resources are listed below.
- Bright Futures website
- Claims and Billing Manual (PDF)
- Claims Status Inquiry - NaviNet
- EPSDT self-paced training (PDF)
- NCDHHS EPSDT website
- Pharmacy Request Form - Non-Covered State Medicaid Plan Services Request Form (Recipients under 21) (PDF)
- Physical Health Request Form - Non-Covered State Medicaid Plan Services Prior Authorization Request Form (Recipients under 21) (PDF)
- Utilization Management (UM) Program Description (PDF)
Provided below are helpful Q&A and links to resources needed to support our members under 21 years of age.
The Pharmacy Services Department at AmeriHealth Caritas North Carolina issues Prior Authorizations for drugs that require clinical review based on NCDHHS clinical criteria requirements and EPSDT criteria. Contact Pharmacy Provider Services at 1-866-885-1406, 24/7, 365 days a year, if you have a question about submission of a Pharmacy EPSDT Prior Authorization.
An EPSDT Pharmacy Prior Authorization can be submitted via:
- Web request under Pharmacy at www.amerihealthcaritasnc.com
- Faxing a completed prior authorization form to 1-877-234-4274
- Pharmacy Request Form - Non-Covered State Medicaid Plan Services Request Form (Recipients under 21) (PDF)
- Calling PerformRx Provider Services at 1-866-885-1406 for verbal prior authorization requests
- Entering an Electronic Prior Authorization (ePA) via your Electronic Health Records (EHR) Platform
Providers receive a fax notifying them of the EPSDT pharmacy prior approval decision.
Using NaviNet, the EP modifier Complete Screen should be used when submitting a preventive service claim.
No, EPSDT preventive services (early and periodic screens/wellness visits) will not require prior authorization from ACNC. Prior authorization may be required for other EPSDT diagnostic and treatment products. Use our Prior Authorization Lookup tool for immediate guidance on prior authorization requirements.
Use our Prior Authorization Lookup tool for immediate guidance on prior authorization requirements and modes of submission for all prior authorization requests (including requests that will be reviewed using EPSDT criteria). Providers receive notification of prior approval decisions by fax and/or telephone call from our Utilization Management team via the provider portal. The decision will be loaded into the portal.
Having confirmed the member is under 21 years of age, claims will be identified based on the presence of third-party liability (TPL) in the member’s record. The claims identified with TPL that also meet the following criteria (A or B), will be paid by ACNC, who will then follow up with the primary carrier for payment:
- Claims for preventive services that do not require prior authorization
- Claims with a prior authorization approved under EPSDT on file for services that require prior authorization
EPSDT claims will be paid in a timely and accurate manner. Medical payment cycles run every Monday, Wednesday and Friday. Pharmacy payment cycles run every four days.
Log into NaviNet and see the Claims Status Inquiry link under Workflows on the left-hand side, or call Provider Services at 1-888-738-0004.
Log into NaviNet and see the Forms and Dashboards link under Workflows on the left-hand side to select Grievance and Appeals. Go to Complete a Grievance. Then fill out the grievance form and submit. Upon submission, write down the Document ID # shown and call Provider Services at 1-888-738-0004 for inquiries.