The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally mandated program for patients age 20 and younger who are eligible for Medical Assistance. Through the EPSDT program, pediatric patients are eligible to receive medical, dental, vision, and hearing screenings to ensure they receive all medically necessary services without regard to Medical Assistance covered services. PCPs are required to ensure all patients age 20 and younger have timely access to EPSDT services and are responsible for ensuring continuation of care for all patients due to receive EPSDT services. PCPs are to arrange for medically necessary follow-up care after a screening or an encounter.
PCPs are responsible for early detection of a child’s problems in development, behavior, social emotional skills, or mental health status. PCPs agree to coordinate ongoing monitoring of care provided by other providers. Providers need to use a reliable validated and standardized tool to make a detection of a child’s problems in development, behavior, social-emotional skills or mental health status, and make appropriate referrals to address any identified problems. Providers should follow the guidelines outlined by Bright Futures Periodicity Schedule, which outlines each age bracket in which a child/teen should be seen and what screenings are done at each interval. PCPs agree to coordinate ongoing monitoring of care provided by other providers. Also, PCPs agree to notify Highmark Health Options when a problem is detected and when a child is referred to a dentist for the first time.
PCPs should complete and fax the EPSDT Member Outreach Ref Form (PDF) to Highmark Health Options for patients who have abnormal findings or did not show up for their appointments, so Highmark Health Options can contact the patient. PCPs are responsible for:
The form must communicate the patient’s demographic information (e.g., telephone number, address, alternate address) to Highmark Health Options staff. This helps with scheduling, locating, and addressing compliance issues.
Highmark Health Options verifies that PCPs and special needs providers are able to provide EPSDT services. PCPs treating patients age 20 and younger who are unable to comply with the requirements of the EPSDT program must make arrangements for EPSDT screenings to be performed elsewhere by an in-network provider. Alternative PCPs and specialists should forward a copy of the completed progress report to the PCP so it can be placed in the patient’s chart.