EPSDT Clinical & Operational Guidelines

UPMC for You adopted Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements based on changes implemented by the Pennsylvania Department of Human Services (DHS) in 2008.

UPMC for You and DHS recognize the importance of comprehensive childhood screenings and providing appropriate and timely follow‐up diagnostic treatment services. We encourage and support physicians in performing EPSDT services. UPMC for You developed EPSDT Clinical and Operational Guidelines to explain our requirements for payments and to provide sample billing instructions. We are also including a sample of the quarterly EPSDT reports, which were implemented in January 2009, and the 2009 immunization schedule.

Announcements

8/2018
Please note that changes have been made to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) periodicity schedule. These changes have been made in response to the Department of Human Services (DHS) Medical Assistance. Bulletins released on August 7, 2017 and January 3, 2018 and are relevant to all Medical Assistance providers. To view the updated EPSDT Periodicity Schedule and UPMC for You billing guide, please see below.

Also remember that all physicians who see Medical Assistance patients under age 21 should perform recommended EPSDT services during the appropriate time frames.

Thank you for continuing to support our goal of providing timely and complete preventive care to our members! For questions, please contact your physician account executive, call Provider Services at 1-866-918-1595, or review the resources below.

Important points to know about the UPMC for You EPSDT requirements:

  • Providers are allowed to perform a sick visit and an EPSDT visit during the same date of service; however, providers cannot bill for both services. A claim will be accepted for either a sick or an EPSDT visit (appropriately billed).
  • The EPSDT service will be paid in full if all of the appropriate services are rendered for the correct EPSDT periodicity visit, per the UPMC for You periodicity chart. Appropriate use of the 52 modifier will not result in a reduced payment. Properly billed claims with the 52 modifiers will receive payments in full.
  • For services that can be provided, but a 52 modifier was used, the provider must complete the service at the next screening.
  • Incorrect billing will result in a reduced rate.

Important information and forms:

Childhood Nutrition and Weight Management Services:

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