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EARLY: Assessing and identifying problems early 

Children covered by Medicaid are more likely to be born with low birth weights, have poor health, have developmental delays or learning disorders, or have medical conditions (e.g., asthma) requiring ongoing use of prescription drugs. Medicaid helps these children and adolescents receive quality health care.

EPSDT is a key part of Medicaid for children and adolescents. EPSDT emphasizes preventive and comprehensive care. Prevention can help ensure the early identification, diagnosis, and treatment of conditions before they become more complex and costly to treat. It is important that children and adolescents enrolled in Medicaid receive all recommended preventive services and any medical treatment needed to promote healthy growth and development.

PERIODIC: Checking children’s health at age-appropriate intervals 

As they grow, infants, children and adolescents should see their health care providers regularly. Each state develops its own “periodicity schedule” showing the check-ups recommended at each age.  Healthy Connections Medicaid has adopted the American Academy of Pediatrics’ Bright Futures guidelines: Recommendations for Preventive Pediatric Health Care.

Bright Futures helps doctors and families understand the types of care that infants, children and adolescents should get and when they should get it. The goal of Bright Futures is to help health care providers offer prevention-based, family-focused, and developmentally-oriented care for all children and adolescents. Children and adolescents are also entitled to receive additional check-ups when a condition or problem is suspected.  

SCREENING: Providing physical, mental, developmental, dental, hearing, vision and other screening tests to detect potential problems 

All infants, children and adolescents should receive regular well-child check-ups of their physical and mental health, growth, development, and nutritional status.

DIAGNOSTIC: Performing diagnostic tests to follow up when a health risk is identified 

When a well-child checkup or other visit to a health care professional shows that a child or adolescent might have a health problem, follow up diagnostic testing and evaluations must be provided under EPSDT. Diagnosis of mental health, substance use and vision, hearing and dental problems are included. Also included are any needed referrals so the child or adolescent can receive necessary treatment.

TREATMENT: Correct, reduce or control health problems found 

EPSDT covers health care, treatment and other measures necessary to correct or ameliorate the child or adolescent’s physical or mental conditions found by a screening or a diagnostic procedure. EPSDT ensures the provision of, and payment for, any treatment that is considered “medically necessary” for the child or adolescent. This includes treatment for any vision and hearing problems, including eyeglasses and hearing aids. For children’s oral health, coverage includes regular preventive dental care and treatment to relieve pain and infections, restore teeth and maintain dental health. Some orthodontia is also covered.

Provider FAQs

Where can I find EPSDT billing and policy information?

Providers may access billing and policy information in the Physicians, Laboratories and other Medical Professional Provider Manual.

What is QTIP?

The Quality through Technology and Innovation in Pediatrics (QTIP) program works to improve health care for children in South Carolina by working on quality measures and incorporating mental health into a medical home. Started in 2010 under a Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) federal grant, this program brings practices together to collaborate on specific measures and foster quality improvement projects at each practice site. Visit QTIP to learn more.

What is considered acceptable screenings for the hearing and vision components of EPSDT at the required age ranges?

South Carolina follows the Bright Futures/AAP Medical Periodicity Schedule for medical, hearing and vision screenings. These guidelines can be found under Sensory Screening on the Bright Futures/AAP Medical Periodicity Schedule. Please note, periodicity schedules and components vary by state. If you are outside of South Carolina, please reach out to your state’s Medicaid agencies.

Who should I contact if I’m having difficulties with a specific claim?

Any questions regarding filing claims, EPSDT or not, should be directed to the Provider Service Center at 888-289-0709.