Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter ALL-155 December 2007 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals, Revised Regulations and Updated EPSDT and PPHSD Information This letter transmits revisions to MassHealth regulations at 130 CMR 450.140 through 450.150, and Appendices W and Z, to update the description of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and preventive pediatric health-care screening and diagnosis (PPHSD) services available to MassHealth members under the age of 21. These regulations are effective December 31, 2007. Overview EPSDT and PPHSD are, collectively, the preventive care and treatment services that MassHealth covers for members under the age of 21 (except MassHealth Limited members). MassHealth pays for these members to see their primary care doctors or nurses on a periodic schedule (at least once every year and more often when they are under the age of two). At these visits, primary care doctors and nurses perform a series of health screens. If the member screens positive, MassHealth pays for further assessment, diagnosis, and treatment services. MassHealth also pays for members under the age of 21 (except MassHealth Limited members) to visit their primary care doctor or nurse between periodic visits (interperiodically) any time there might be something wrong. For members entitled to EPSDT services, MassHealth pays for all medically necessary assessment, diagnosis, and treatment services that are covered by federal Medicaid law, even if the services are not described in a MassHealth contract, regulation, or service code covered for the member’s coverage type. These revised regulations: • Indicate that, in addition to MassHealth Standard members under 21, MassHealth CommonHealth members under 21 are entitled to EPSDT services. Formerly, MassHealth CommonHealth members under 21 were entitled to PPHSD services; • expressly include behavioral health (mental health and substance abuse) and developmental screens in the list of screening services covered during an EPSDT or PPHSD visit; • mandate that primary care providers offer to conduct EPSDT and PPHSD screens according to Appendix W (EPSDT Periodicity Schedule) and provide or refer such members to assessment, diagnosis, and treatment services, as necessary; • clarify that providers requesting prior authorization for EPSDT services for members enrolled in a managed care organization must direct those requests to the managed care organization in which the member is enrolled; • update the description of the vision screening test covered during an EPSDT or PPHSD visit; and • indicate that primary care providers who conduct behavioral health screens according to Appendix W (EPSDT Periodicity Schedule) will receive a separate payment for the screen in addition to the rate for the visit. Appendix W (EPSDT Periodicity Schedule) has been revised to update the procedures for conducting hearing, developmental, and behavioral health screening, and the sources of anticipatory guidance provided at periodic and interperiodic EPSDT and PPHSD visits. Appendix Z (EPSDT/PPHSD Screening Services Codes) has been revised to update the list of Current Procedural Terminology (CPT) codes that are reimbursable for laboratory services, hearing tests, and vision tests during a periodic or interperiodic EPSDT or PPHSD visit. A new code has been added for the behavioral health screens that are mandated in the all-provider regulations. There is more information about certain of these revisions below. Mandate for Primary Care Providers to Offer to Conduct EPSDT/PPHSD Screens and Refer Members for Further Diagnosis and Treatment MassHealth is requiring all primary care providers to offer to conduct periodic and medically necessary interperiodic EPSDT and PPHSD screens for MassHealth members under the age of 21 (except those with MassHealth Limited coverage) according to the EPSDT Periodicity Schedule. MassHealth is also requiring primary care providers to provide or refer members to needed assessment, diagnosis, and treatment services. MassHealth defines “primary care providers” as: • general practitioners; • family physicians; • internal medicine physicians; • obstetrician/gynecologists; • pediatricians; • independent nurse practitioners; and • independent nurse midwives. These providers must offer to conduct screens when they practice in an individual or group practice, in the outpatient department of a hospital (acute or chronic and rehabilitation hospital), or in a community health center. Primary care services do not include emergency or poststabilization services provided in a hospital or other setting. Therefore, primary care providers practicing in these settings are not required to offer to conduct screens according to Appendix W (EPSDT Periodicity Schedule), when practicing in those settings. Developmental and Behavioral Health Screens In particular, MassHealth is expressly including developmental and behavioral health (mental health and substance abuse) screens in the list of EPSDT/PPHSD screens. MassHealth also is revising Appendix W (EPSDT Periodicity Schedule) to require that providers choose a clinically appropriate behavioral health screening tool from a menu of approved, standardized tools when conducting a behavioral health screen at a periodic or interperiodic visit. These standardized behavioral health screening tools are described in more detail below. Menu of Standardized Behavioral Health Screening Tools in Appendix W The menu of behavioral health screening tools that primary care providers must use during EPSDT and PPHSD visits is published in Appendix W (EPSDT Periodicity Schedule). These tools accommodate a range of ages while permitting some flexibility for provider preference and clinical judgment. For your convenience, the menu of approved tools is reproduced below in Table 1, “Behavioral Health Screening Tools” along with a description of who completes the tool and the appropriate age group for the tool. Please note that Table 1 is for your information only. The EPSDT Periodicity Schedule controls the approved behavioral health screening tools. Table 1. Behavioral Health Screening Tools Who completes the tool Appropriate age group for the tool ASQ:SE Ages and Stages Questionnaires: Social-Emotional http://www.brookespublishing.com/tools/asqse/index.htm Parent 4 - 60 months BITSEA Brief Infant and Toddler Social and Emotional Assessment http://harcourtassessment.com/HAIWEB/Cultures/en- us/Productdetail.htm?Pid=015-8007-352&Mode=summary Parent 12 to 36 months CBCL YSR ASR Achenbach System: Child Behavior Checklist Youth Self-Report Adult Self-Report http://www.ASEBA.org Parent Youth Young Adult 1.5 to 18 years 11 to 18 years 18 to 59 years CRAFFT Car, Relax, Alone, Forget, Friends, Trouble http://www.ceasar-boston.org/clinicians/crafft.php Screening for substance abuse Youth 14 + M-CHAT Modified Checklist for Autism in Toddlers http://www.dbpeds.org/media/mchat.pdf (tool) http://www.dbpeds.org/articles/detail.cfm?TextID=377 (background) Screening for autism Parent 18 to 30 months PEDS Parents’ Evaluation of Developmental Status http://www.pedstest.com Parent Birth to 8 years PHQ-9 Patient Health Questionnaire-9 http://www.phqscreeners.com/ Screening for depression Young Adult 18+ PSC Y-PSC Pediatric Symptom Checklist Pediatric Symptom Checklist-Youth Report http://psc.partners.org/ Parent Youth 4 thru 16 years 11+ years How to Claim for the Standardized Behavioral Health Screening Tools MassHealth will pay for the administration and scoring of the behavioral health tools listed in the EPSDT Periodicity Schedule (Appendix W) when administered by: • physicians; • independent nurse practitioners; • independent nurse midwives; and • nurse practitioners, nurse midwives, and physician assistants under a physician’s supervision. MassHealth will reimburse for the administration of one standardized behavioral health screening tool per MassHealth member, per day, regardless of the number of behavioral health screening tools administered on the same day for a given member. MassHealth will pay for behavioral health screening tools administered and scored in accordance with Appendix W (EPSDT Periodicity Schedule) separately from, and in addition to, the rate for the periodic or interperiodic EPSDT and PPHSD visits. Claims for the behavioral health screening tool must be submitted using Current Procedural Terminology (CPT) Service Code 96110. MassHealth is amending Appendix Z (EPSDT/PPHSD Screening Services Codes) to include this code. For more information about the reimbursement rates for the administration and scoring of the behavioral health screening tools, please see the Division of Health Care Finance and Policy Web site at www.mass.gov/dhcfp. The following provider types can submit claims for reimbursement for the standardized behavioral health screening tools: • physicians; • independent nurse practitioners; • independent nurse midwives; • community health centers; and • hospital outpatient departments. Please note that distinct modifiers are required when billing the CPT code for the behavioral health screening tools. Effective July 1, 2008, failure to include the modifier will result in denial of the claim. These modifiers will allow MassHealth to track the disposition of the screen so that MassHealth will know the number of members with a behavioral health need identified. These modifiers vary by provider type. Please see Table 2, “Modifiers for Use with Service Code 96110” for direction on the appropriate modifier to use. Table 2. Modifiers for Use with Service Code 96110 Servicing Provider Modifier for Use When No Behavioral Health Need Identified * Modifier for Use When Behavioral Health Need Identified * Physician, Independent Nurse Midwife, Independent Nurse Practitioner, Community Health Center (CHC), Outpatient Hospital Department (OPD) U1 U2 Nurse Midwife employed by Physician or CHC U3 U4 Nurse Practitioner employed by Physician or CHC U5 U6 Physician Assistant employed by Physician or CHC U7 U8 * Behavioral health need identified includes needs in the area of behavioral health, social- emotional well-being, or mental health. The text of the CPT code and modifiers required to claim for the standardized behavioral health screening tools are listed in Table 3, “Text of CPT Code and Modifiers for Claiming the Standardized Behavioral Health Screening Tools.” Please note that this list of codes is for your information only. See Subchapter 6 of your MassHealth provider manual for the codes and modifiers that are required to claim for the administration and scoring of the behavioral health screening tool. Table 3. Text of CPT Code and Modifiers for Claiming the Standardized Behavioral Health Screening Tools Service Code/ Modifer Text of Code/Modifier CPT 96110 Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report U1 Physician, independent nurse midwife, independent nurse practitioner, community health center (CHC), outpatient hospital department (OPD), completed behavioral health screening with no behavioral health need identified U2 Physician, independent nurse midwife, independent nurse practitioner, community health center (CHC), outpatient hospital department (OPD), completed behavioral health screening and behavioral health need identified U3 Nurse midwife (SB) employed by physician or CHC, completed behavioral health screening with no behavioral health need identified U4 Nurse midwife (SB) employed by physician or CHC, completed behavioral health screening and behavioral health need identified U5 Nurse practitioner (SA) employed by physician or CHC, completed behavioral health screening with no behavioral health need identified U6 Nurse practitioner (SA) employed by physician or CHC, completed behavioral health screening and behavioral health need identified U7 Physician assistant (HN) employed by physician or CHC, completed behavioral health screening with no behavioral health need identified U8 Physician assistant (HN) employed by physician or CHC, completed behavioral health screening and behavioral health need identified Training on How to Administer and Claim the Standardized Behavioral Health Screening Tools MassHealth will offer training opportunities for providers to learn more about how to administer and claim for administration of the standardized behavioral health screening tools listed in Appendix W (EPSDT Periodicity Schedule), and reproduced above in Table 1. Training on how to administer the standardized behavioral health screening tools will be available online. For more information, please visit the MassHealth Web site for child behavioral health that will be available starting on Monday, December 31, 2007: www.mass.gov/masshealth/childbehavioralhealth. There is more information about this Web site below. Training on how to claim for the administration of the standardized behavioral health screening tools is also available. You can contact MassHealth Customer Service at 1-800- 841-2900 for more information on these trainings. Child Behavioral Health Information on the Web Starting Monday, December 31, 2007, the MassHealth Web site will contain information about children’s behavioral health, including useful links for finding additional information. To get to this new area on the MassHealth Web site, go to www.mass.gov/masshealth/childbehavioralhealth. Bookmark this page for future reference, as MassHealth will be adding new information to this Web site over time. Reminder to Verify Eligibility MassHealth requires providers to use the Recipient Eligibility Verification System (REVS) to verify members’ day-to-day eligibility status, coverage type, managed care enrollment status, restrictions, and third-party insurance coverage information. The data in the REVS provides you with the most up-to-date eligibility information at the time of service. Questions If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages i, 1-25 through 1-32, W-1 through W-6, and Z-1 and Z-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Page i — transmitted by Transmittal Letter ALL-125 Pages 1-25 and 1-26 — transmitted by Transmittal Letter ALL-147 Pages 1-27 and 1-28 — transmitted by Transmittal Letter ALL-113 Pages 1-29 through 1-32 — transmitted by Transmittal Letter ALL-118 Pages W-1 through W-6 and — transmitted by Transmittal Letter ALL-137 Pages Z-1 and Z-2 — transmitted by Transmittal Letter ALL-111 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page i All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 1. Introduction 450.101: Definitions..................................................................... .................................... 1-1 450.102: Purpose of 130 CMR 400.000 through 499.000................................................ 1-5 450.103: Promulgation of Regulations..................................................................... ........ 1-5 (130 CMR 450.104 Reserved) 450.105: Coverage Types........................................................................... ...................... 1-6 450.106: Emergency Aid to the Elderly, Disabled and Children Program....................... 1-14 450.107: Eligible Members and the MassHealth Card..................................................... 1-15 450.108: Selective Contracting..................................................................... .................... 1-16 450.109: Out-of-State Services........................................................................ ................. 1-16 (130 CMR 450.110 and 450.111 Reserved) 450.112: Advance Directives...................................................................... ...................... 1-16 (130 CMR 450.113 through 450.116 Reserved) 450.117: Managed Care Participation................................................................... ............ 1-18 450.118: Primary Care Clinician (PCC) Plan................................................................... 1-18 (130 CMR 450.119 through 450.123 Reserved) 450.124: Behavioral Health Services........................................................................ ........ 1-23 (130 CMR 450.125 through 450.129 Reserved) 450.130: Copayments Required by MassHealth............................................................... 1-24 (130 CMR 450.131 through 450.139 Reserved) 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction.................................................................... .................................... 1-26 450.141: EPSDT Services: Definitions..................................................................... ....... 1-26 450.142: EPSDT Services: Medical Protocol and Periodicity Schedule (Screening)...... 1-27 450.143: EPSDT Services: Description of EPSDT Visits............................................... 1-27 450.144: EPSDT Services: Diagnosis and Treatment...................................................... 1-28 450.145: EPSDT Services: Claims for Visits.................................................................. 1-29 450.146: EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Independent Nurse Practitioner, Independent Nurse Midwife, and Community Health Center Only) ................................................................................ ........................................... 1-30 (130 CMR 450.147 Reserved) 450.148: EPSDT Services: Payment for Transportation.................................................. 1-30 450.149: EPSDT Services: Recordkeeping Requirements.............................................. 1-30 450.150: Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) for Certain MassHealth Members...................................................................... 1- 31 (130 CMR 450.151 through 450.199 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-25 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 (h) independent foster care adolescents who were in the care and custody of the Department of Social Services on their 18th birthday and who are eligible for MassHealth Standard until they reach age 21. (2) Members who have accumulated copayment charges totaling the calendar-year maximum of $200 on pharmacy services do not have to pay further MassHealth copayments on pharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for pharmacy services. (3) Members who have accumulated copayment charges totaling the calendar-year maximum of $36 on non-pharmacy services do not have to pay further MassHealth copayments on nonpharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for nonpharmacy services. (4) Members who have other comprehensive medical insurance, including Medicare, do not have to pay MassHealth copayments on nonpharmacy services. (5) Members who are inpatients in a hospital do not have to pay a separate copayment for pharmacy services provided as part of the hospital stay. (E) Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 450.130(B): (1) family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories; (2) nonpharmacy behavioral health services; and (3) emergency services. (F) Notice to Members about Exclusions from the Copayment Requirement. Pharmacies and hospitals must post a notice about MassHealth copayments in areas where copayments are collected. The notice must be visible to the public and easily readable and must specify the exclusions from the copayment requirement listed in 130 CMR 450.130(D) and (E), and instruct members to inform providers if members believe they are excluded from the copayment requirement. (G) Collecting Copayments. (1) A member must pay the copayment described in 130 CMR 450.130(B) at the time the service is provided unless the member is exempt under 130 CMR 450.130(D) or (E), claims that he or she is exempt from the copayment, or claims that he or she is unable to make the copayment at the time the service is provided. The member's inability to make the copayment at the time service is provided does not eliminate the member's liability for the copayment, and providers may bill the member for the copayment amount. (2) The MassHealth agency will deduct the amount of the copayment from the amount paid to the provider, whether or not the provider collects the copayment from the member, unless the member or service is exempt according to 130 CMR 450.130(D) or (E). Providers should not deduct the copayment amount from the amount claimed. Providers may not refuse services to any members who are unable to pay the copayment at the time service is provided. (H) Receipt. The provider must give the member a receipt identifying the provider, service, date of service, member, and amount paid. (I) Recordkeeping. Providers must keep all records necessary to determine if a copayment was collected from a member for a service on a specific date. (130 CMR 450.131 through 450.139 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-26 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction (A) Legal Basis. (1) In accordance with federal law at 42 U.S.C. § 1396d(a)(4)(b) and (r) and 42 CFR 441.50, and notwithstanding any limitations implied or expressed elsewhere in MassHealth regulations or other publications, the MassHealth agency has established a program of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for MassHealth Standard and MassHealth CommonHealth members under age 21 years, including those who are parents. (2) Any MassHealth provider may deliver EPSDT services. However, in delivering well- child care, providers must follow the EPSDT Medical Protocol and Periodicity Schedule. (3) EPSDT screening services include among other things, health, vision, dental, hearing, behavioral health, developmental and immunization status screening services. (4) The regulations governing the EPSDT program are set forth in 130 CMR 450.140 through 450.149. (B) Program Objectives. The objectives of the EPSDT program are (1) to provide comprehensive and continuous health care designed to prevent illness and disability; (2) to foster early detection and prompt treatment of health problems before they become chronic or cause irreversible damage; (3) to create an awareness of the availability and value of preventive well- child care services; and (4) to create an awareness of the services available under the EPSDT program, and where and how to obtain those services. 450.141: EPSDT Services: Definitions EPSDT Medical Protocol and Periodicity Schedule (the Schedule) — a schedule (see Appendix W of all MassHealth provider manuals) developed and periodically updated by the MassHealth agency in consultation with the Massachusetts Chapter of the American Academy of Pediatrics, Massachusetts Department of Public Health, dental professionals, the Massachusetts Health Quality Partners, and other organizations concerned with children's health. The Schedule consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. Interperiodic Visit — the provision of screening procedures or treatment services at an age other than those indicated on the Schedule. Interperiodic visits may be: (1) screenings that are medically necessary to determine the existence of a suspected illness or condition, or a change in or complication of a preexisting condition; (2) the provision of the full-range of EPSDT screening or treatment services delivered at an age other than one listed on the Schedule to update the member's care according to the Schedule; or (3) additional screening or treatment services provided to a member whose care is already up- to-date according to the Schedule. Periodic Visit — the provision of screening procedures appropriate to the member's age and medical history, as prescribed by the Schedule. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-27 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 Primary Care — health care services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, independent nurse practitioner, or independent nurse midwife, to the extent the furnishing of those services is legally authorized in the Commonwealth. Primary care does not include emergency or poststabilization services provided in a hospital or other setting. Primary Care Provider — a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, independent nurse practitioner or independent nurse midwife. 450.142: EPSDT Services: Medical Protocol and Periodicity Schedule (Screening) (A) Providers of Periodic and Interperiodic Visits. (1) Primary care providers must offer to conduct periodic and medically necessary interperiodic visits to screen all members under age 21 (except members enrolled in MassHealth Limited) in accordance with the Schedule, and must provide or refer such members to assessment, diagnosis and treatment services. (2) Hospitals and community health centers that provide primary care services must offer to conduct periodic and medically necessary interperiodic visits to screen all members under age 21(except members enrolled in MassHealth Limited) in accordance with the Schedule, and must provide or refer such members to assessment, diagnosis, and treatment services. (3) The health assessments described in the Schedule are payable when provided by a physician, independent nurse practitioner, independent nurse midwife, hospital, community health center, or nurse practitioner, nurse midwife or physician' assistant under a physician's supervision. (B) Explanation of Procedures. (1) The Schedule outlines the procedures for comprehensive preventive care that help to identify members who may require further diagnosis of suspected or actual health problems, treatment of these problems, or both. (2) Explanation of procedures that must be maintained in the medical record to substantiate the performance of such procedures are provided in the Schedule. 450.143: EPSDT Services: Description of EPSDT Visits (A) Initial EPSDT Visit. (1) An initial EPSDT visit must be provided for every (a) new member; (b) member previously seen only for sick care; and (c) newborn previously seen only in the hospital. (2) An initial EPSDT visit includes the recording of (a) family, medical, behaviorial health, developmental, and immunization history; (b) a review of all systems; (c) a comprehensive physical examination; and (d) all exams, assessments, screening, and laboratory work indicated on the Schedule as appropriate for the member's age. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-28 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 (B) EPSDT Periodic Visit. (1) An EPSDT periodic visit consists of all exams, assessments, screenings, and laboratory work indicated on the Schedule as appropriate for the member's age. (2) A provider may claim payment for an EPSDT periodic visit only when all the screening procedures on the Schedule that correspond to the member's age have been delivered to the member. (a) While the screening procedures are based upon a presumption of regular contact with health-care providers, many members will need additional screening procedures to bring them up to date. (b) It is the provider's responsibility to provide those additional screening procedures necessary to bring the member up to date with his or her preventive health care according to the Schedule. (3) If the provider is unequipped to perform a test (for example, if he or she does not have an audiometer and an audiometric test is required), the provider must make a screening referral to another provider. However, in every case, for the referring provider to claim payment for an EPSDT periodic visit (a) all required screening procedures must be performed; and (b) the referring provider must receive and document all results in the member’s medical record. (C) EPSDT Interperiodic Visit. An EPSDT interperiodic visit is any visit not indicated on the Schedule. Such visits may be either (1) preventive health-care visits provided at an age or age interval not indicated on the Schedule; or (2) a screening that is medically necessary to determine the existence of a suspected illness or condition, or a change in or complication of a preexisting condition. 450.144: EPSDT Services: Diagnosis and Treatment (A) (1) EPSDT diagnosis and treatment services consist of all medically necessary services listed in §1905(a) of the Social Security Act (42 U.S.C. §1396d(a) and (r)) that are (a) needed to correct or ameliorate physical or mental illnesses and conditions discovered by a screening, whether or not such services are covered under the State Plan; and (b) payable for MassHealth Standard and MassHealth CommonHealth members under age 21 years, if the service is determined by the MassHealth agency to be medically necessary. (2) To receive payment for any service described in 130 CMR 450.144(A)(1) that is not specifically included as a covered service under any MassHealth regulation, service code list, or contract, the requester must submit a request for prior authorization in accordance with 130 CMR 450.303. This request must include, without limitation, a letter and supporting documentation from a MassHealth-enrolled physician, nurse practitioner, or nurse midwife documenting the medical need for the requested service. If the MassHealth agency approves such a request for service for which there is no established payment rate, the MassHealth agency will establish the appropriate payment rate for such service on an individual- consideration basis in accordance with 130 CMR 450.271. If the request is for a member who is enrolled in a MassHealth-contracted managed care organization, as defined in 130 CMR 508.000, the requestor must submit the request to the managed care organization according to the managed care organization’s prior- authorization process. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-29 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 (B) For any condition that requires further assessment, diagnosis or treatment after the periodic or interperiodic visit, the provider must inform the member how and where to obtain further assessment, diagnosis or treatment, and must either: (1) request that the member return for another appointment as soon as possible; or (2) make a referral to another provider who can provide the appropriate assessment, diagnosis, or treatment as soon as the referring provider determines that a referral is needed. (C) When making a referral to another provider, the referring provider must give the name and address of an appropriate provider to the member or to the member's parent or guardian. (D) The referring provider must obtain a report of the results of assessment, diagnosis, and treatment from the provider of the referred service and document this information in the member's medical record. 450.145: EPSDT Services: Claims for Visits (A) Initial EPSDT Visit. A provider may bill for only one initial EPSDT visit per member. (B) Periodic Visits. (1) For each member from birth through two years of age, a provider may bill for only one periodic visit per age level listed in the Schedule. (2) For each member aged two years through 20 years, a provider may bill for only one periodic visit every year. (C) Interperiodic Visits. There is no limit on the number of medically necessary interperiodic visits that may be billed. Only interperiodic visits, at which the full range of EPSDT screening services are delivered, are payable as EPSDT periodic visits, subject to the limitations in 130 CMR 450.145(B). Any other interperiodic visit is payable according to the visit service codes and descriptions in Subchapter 6 of the screening provider's MassHealth provider manual. (D) Newborn Visits. (Physician, Independent Nurse Practitioner, Independent Nurse Midwife and Community Health Center Only) (1) To be paid for an EPSDT periodic visit of a newborn, the provider must have visited the newborn at least twice before the newborn leaves the hospital. (a) The first visit, for an initial history and physical examination, is payable as newborn care and not as an EPSDT periodic visit. (b) The second visit, for a discharge history, physical examination, and all other screens required for the newborn, is payable as an EPSDT periodic visit. (2) Additional hospital visits for ill newborns are payable according to the service codes and descriptions for hospital visits. (3) The newborn EPSDT periodic visit may occur at the provider's office if the infant's length of stay in the hospital is not long enough for the provider to visit the infant twice before the infant is discharged from the hospital. (E) Reporting Requirement. To claim payment for an EPSDT initial, periodic, or interperiodic visit, a provider must submit a completed claim according to the billing instructions in Subchapter 5 of his or her MassHealth provider manual. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-30 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 450.146: EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Independent Nurse Practitioner, Indpendent Nurse Midwife, and Community Health Center Only) (A) Laboratory Services. The laboratory services that are listed in Appendix Z of all MassHealth provider manuals and included in the Schedule are payable, in addition to the initial, periodic, or interperiodic visit, when they are performed and interpreted in the office of the provider who provided the initial, periodic, or interperiodic visit. (B) Audiometric Hearing and Vision Tests. - Payment for the audiometric hearing test and the bilateral quantitative screening test of visual acuity that are listed in Appendix Z of all MassHealth provider manuals and included in the Schedule, is not included in the fee for an initial, periodic, or interperiodic visit. Payment for these tests may be claimed separately. (C) Behavioral Health Screening. - Payment for the administration and scoring of one of the standardized behavioral health screening tools that is listed in Appendix Z of all MassHealth provider manuals and set forth in the Schedule is not included in the fee for an initial, periodic, or interperiodic visit. (130 CMR 450.147 Reserved) 450.148: EPSDT Services: Payment for Transportation Transportation may be available to members accessing EPSDT services. Providers must ask members if they need transportation assistance, and refer those members who do to MassHealth Customer Service for additional information about transportation. 450.149: EPSDT Services: Recordkeeping Requirements (A) Medical Records. (1) A provider must create and maintain a record for every member receiving EPSDT services, in accordance with MassHealth regulations governing medical records at 130 CMR 450.205. (2) In addition, the medical record for each member receiving EPSDT services must contain documentation of the screening procedures listed in the Schedule as well as the following: (a) the results of all laboratory tests; (b) the name of each referral provider; and (c) the results of any component of the Schedule that was delivered by another provider. (B) Determination of Compliance with Medical Standards. The MassHealth agency may review the medical records of members receiving EPSDT services to determine the necessity and quality of the medical services provided. Any such determinations will be made in accordance with 130 CMR 450.206. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-31 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 450.150: Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) Services for Certain MassHealth Members (A) MassHealth has established a program of preventive pediatric health-care screening and diagnosis services for MassHealth members under the age of 21 years who are enrolled in MassHealth Basic, MassHealth Essential, MassHealth Prenatal, and MassHealth Family Assistance. MassHealth Standard and MassHealth CommonHealth members are entitled to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services pursuant to 130 CMR 450.140. (B) Any qualified MassHealth provider may deliver preventive pediatric health- care screening and diagnosis services. (1) In delivering preventive pediatric health-care screening and diagnosis services, providers must (a) follow the procedures listed in the Schedule; and (b) comply with the regulations at 130 CMR 450.140 through 450.150. (2) Preventive pediatric health-care screening and diagnosis services include health, vision, dental, hearing, and immunization status screening services. (3) To interpret the applicable EPSDT regulations for children enrolled in MassHealth Basic, MassHealth Essential, MassHealth Prenatal, and MassHealth Family Assistance, providers should substitute the term, preventive pediatric health-care diagnosis and treatment services, for the term, Early and Periodic Screening, Diagnosis and Treatment Services, wherever it appears. (C) Providers delivering preventive pediatric health-care screening and diagnosis services should provide members with, or refer members for, additional diagnosis and treatment services according to 130 CMR 450.105. (130 CMR 450.151 through 450.199 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-32 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-1 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Medical Protocol and Periodicity Schedule The EPSDT Medical Protocol and Periodicity Schedule consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services. Pediatric preventive health-care visits – Pediatric preventive health-care visits must .. contain the components explained in the descriptions in the EPSDT Medical Protocol and Periodicity Schedule; and .. occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday. Initial or Interval Health History .. Initial – An initial history must be taken at the first EPSDT or PPHSD visit delivered to a member by a provider. The initial health history includes the family health history and baseline data on the member, including but not limited to (a) growth and developmental history; (b) immunization history; (c) known reactions to medications and allergies; and (d) pertinent information about previous illnesses and hospitalizations, risk- taking behaviors, such as drug, alcohol, and tobacco use, sexual activity, and other medical, psychosocial, and behavioral health concerns. .. Interval – An interval history must be taken at each periodic EPSDT or PPHSD visit. The interval history includes an update of the member’s medical history, including but not limited to: (a) a review of all systems and any illnesses, diseases, medications, or medical problems experienced by the member since the last visit; and (b) an updated assessment of lifestyle, risk behavior, sexual activity, psychosocial, and behavioral health concerns. Comprehensive Physical Examination – Each EPSDT or PPHSD visit must include an unclothed physical examination, including .. assessment of growth parameters using height and weight. Include head- circumference measurements until the age of two years. Measurements must be plotted on appropriate growth charts. Screen for overweight using the Centers for Disease Control and Prevention (CDC) body mass index (BMI) charts for members aged two through 20 years; .. blood pressure at age three years and older; .. sensory screening, including vision and hearing; .. oral-health assessment; and .. pelvic examination within three years after the first sexual intercourse and thereafter every one to three years based on risk factors, at the clinician’s discretion, but no later than age 21. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-2 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 Nutritional Assessment .. Each EPSDT or PPHSD visit must include an evaluation of the member's nutritional health, including (a) medical history; (b) diet history; (c) physical examination; (d) height, weight, and BMI; (e) head-circumference measurements, as appropriate; and (f) laboratory tests to screen for iron deficiency and elevated cholesterol, if indicated. .. Providers must make every effort to inform the member or his or her parent or guardian about the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), if the provider believes that the child may be eligible for WIC. A referral to WIC should be made using the WIC Medical Referral Form (MRF) from the Massachusetts WIC Program. .. The member, parent, or guardian may also be referred to the Food Stamp Program, which is administered by the Department of Transitional Assistance. Developmental Screening and Behavioral Health Screening .. At each EPSDT or PPHSD visit, the provider must screen the member for delays or differences in functioning in the following areas, as appropriate to the member's age: (a) physical development, including gross motor development (strength, balance, and locomotion), fine motor development (hand-eye coordination), and sexual development; (b) cognitive development, including self-help and self-care skills and cognitive skills (problem-solving and reasoning abilities); (c) language development, including expression, comprehension, and articulation; and (d) psychosocial and behavioral development, including an assessment of social integration and peer relations, behavioral difficulties, such as sleep disturbances and aggression, psychological problems, such as depression, risk-taking behavior, and school performance. .. Essential components of the screening process include, but are not limited to (a) sensitive attention to member, parent, or guardian concerns about the member; (b) thoughtful inquiry about parent or guardian observations; (c) observation by the provider and the member’s parent or guardian about the member’s behaviors; (d) examination of specific developmental attainments; and (e) observation of member and parent or guardian interaction. .. In performing the developmental screening, the provider may utilize specific clinically appropriate developmental screening instruments including, but not limited to (a) Ages and Stages Questionnaire (ASQ); (b) Bayley Infant Neurodevelopmental Screener (BINS); (c) BRIGANCE screens; (d) Child Development Inventories; (e) Denver Developmental Screening Test II; (f) Early Language Milestone Scale; (g) Parents Evaluation of Developmental Status (PEDS); and (h) Parents Evaluation of Developmental Status: Developmental Milestones (PEDS: DM). Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-3 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 .. Providers must inform the parent or guardian about the benefits of developmental intervention and special education services if a concern is identified. To access these services for any member who is between birth and three years old, the member should be referred to the local Early Intervention program of the Massachusetts Department of Public Health. If the child is between two years six months and three years old, a referral to the local public school system should also be made. For children over the age of three, a referral should be made to the local public school system. Early Intervention and/or the local public school will conduct assessments to determine eligibility and service needs. .. In performing the behavioral health screening, providers must utilize a clinically appropriate tool from the following list of approved, standardized behavioral health screening tools: (a) Ages and Stages Questionnaires (ASQ: SE); (b) Brief Infant-Toddler Social and Emotional Assessment (BITSEA); (c) Child Behavior Checklist (CBCL), Youth Self-Report (YSR), and Adult Self- Report (ASR) of the Achenbach System; (d) Car, Relax, Alone, Forget, Friends, Trouble, (CRAFFT) – (screening for substance abuse); (e) Modified Checklist for Autism in Toddlers (M-CHAT) – (screening for autism); (f) Parents’ Evaluation of Developmental Status (PEDS); (g) Patient Health Questionnaire-9 (PHQ-9) – (screening for depression); or (h) Pediatric Symptom Checklist (PSC) and Pediatric Symptom Checklist-Youth Report (Y-PSC). .. If there is evidence of a behavioral health concern, or need for further assessment, providers must offer the necessary behavioral health services or make a referral to another provider who can provide the appropriate services. Providers can seek assistance from MassHealth or a member’s health plan to determine what providers may be available to provide these services and how to utilize out of network providers, if necessary. Hearing Screening – An objective hearing screening must be performed using an audiometer or otoacoustic emissions at the following frequencies: 1,000 Hz, 2,000 Hz, and 4,000 Hz tones at 20 dB HL, at the following ages: four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. .. If the objective hearing screen is performed in another setting, such as a school, the screening does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Conduct a subjective hearing assessment at all other routine checkups. Conduct audiologic monitoring every six months until the age of three years if there is a language delay or risk of hearing loss. .. If the provider receives notification of a missed or failed newborn hearing screen, then the provider should ensure that a new screening or diagnostic follow-up takes place. Providers should contact the Massachusetts Department of Public Health’s Universal Newborn Hearing Screening Program for additional information about the newborn hearing screening. Vision Screening .. Assess newborns before discharge or at least by the age of two weeks, including corneal light reflex and red reflex. .. Evaluate fixation preference, alignment, and eye disease by the age of six months and at each subsequent well-child visit. .. Screen for strabismus between the ages of three years and five years. An objective vision acuity screening must be performed at the following ages: three years, four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-4 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 .. Screen children at entry to kindergarten if they have not been screened during the previous 12-month period (2004 MA law) using the Massachusetts Preschool Vision Screening Protocol. Children who fail to pass the vision screening and children with neurodevelopmental delay must be referred to a licensed optometrist or ophthalmologist. .. If the objective vision screen is performed in another setting, such as a school, the screen does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Dental Assessment and Referral – The screening provider must encourage members to seek regular dental care from a dental provider, beginning at the age of three years, or earlier, if indicated, including examinations once every six months, preventive services, and treatment, as necessary. Intraoral assessments should identify obvious dental problems and ensure that regular visits to a dental provider are occurring by three years of age. .. Assess oral health at each visit. Assess the need for fluoride supplementation starting at the age of six months continuing through four years of age. Counsel on good dental-hygiene habits, fluoride supplementation, and prevention of infant caries, including avoidance of bottle-propping. Cancer Screening and Examination .. Perform a Pap smear within three years after the first sexual intercourse and thereafter every one to three years based on risk factors, at the clinician’s discretion, but no later than the age of 21 years. .. Perform a clinical breast exam and provide breast self-exam instruction at every visit for female members beginning at the age of 18 years. .. Perform a clinical testicular exam and provide self-exam instruction for male members annually beginning at the age of 15 years. .. Screen all members for the presence of other cancers as indicated by member or family history. Health Education and Anticipatory Guidance .. At every EPSDT or PPHSD visit, age-specific and appropriate counseling must be delivered to parents or guardians and members, if age-appropriate, about common and expected developmental advancements and common physical problems. .. Effective discussion includes assessment and teaching based on a family- centered, culturally competent approach. Discussion topics should include, but not be limited to (a) concerns of the member, parent(s), or guardian(s); (b) developmental expectations and sound parenting practices; (c) behavioral risks, such as substance use and violence, sexuality, HIV/AIDS and other communicable diseases, depression, injury prevention, and nutrition; and (d) safety measures, including car seats, bike helmets, poison prevention, gun safety, and other age- appropriate counseling. .. Educational activities and resources (such as printed brochures, audiovisual materials, class instruction, and health-risk questionnaires) can enhance comprehensive child and adolescent health supervision, but should not replace interaction between the provider and the member. .. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents—Third Edition and the American Medical Association’s (AMA) Guidelines for Adolescent Preventive Services (GAPS) provide lists of topics that may be discussed, and resources for providers, parents, guardians, and members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-5 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 Immunization Assessment and Administration – At every EPSDT or PPHSD visit, the provider must assess the member’s immunization status and administer all immunizations for which the member is due in accordance with the recommendations of the Department of Public Health’s Immunization Program. Lead Toxicity Screening .. Providers must screen every member for lead toxicity according to the requirements for lead toxicity screening set forth by the Massachusetts Childhood Lead Poisoning Prevention Program (MCLPPP). These requirements can be found at 105 CMR 460.050 et seq. .. If a child is found to have a blood lead level equal to or greater than 10 micrograms per deciliter, providers should use their professional judgment, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines about patient management and treatment, as well as follow-up blood tests. .. Physicians and other health-care providers must report all cases of childhood lead poisoning (equal to or greater than 10 micrograms per deciliter) known to them to the Director of the MCLPPP within three working days of identification, unless that episode has been previously reported. (a) When a child has multiple episodes of lead poisoning, each episode must be reported. (b) Initiation of investigations to determine the source of lead in the child’s environment is provided by the MCLPPP. Tuberculin Test – The screening provider must assess a child’s risk at every periodic visit and administer a Mantoux test to children determined to be at high risk for contracting tuberculosis. Hematocrit or Hemoglobin Test .. The screening provider must obtain the hematocrit/hemoglobin test for iron deficiency according to the following: (a) once between nine months and 12 months of age; (b) as needed, at the clinician’s discretion for members aged one year through 10 years; and (c) annually, at the clinician’s discretion for members aged 11 years through 17 years. Cholesterol Screening – Screen children aged two years through 17 years at least once if they have a family history of premature cardiovascular disease or a parent with known lipid disorder and/or a parent with BMI greater than the 85th percentile. Screen once between the ages of 18 years and 21 years, if not screened previously. Urinalysis – Conduct once at about five years of age at the clinician’s discretion. Hepatitis C – Obtain anti-Hepatitis C virus test after the age of 12 months in children with mothers infected with hepatitis C virus. Sexually Transmitted Infections – Test all sexually active adolescents and young adults annually for gonorrhea and chlamydia, and according to the member’s risk and the provider's professional judgment for syphilis and any other sexually transmitted infections. Screen for syphilis, gonorrhea, and Chlamydia during pregnancy, if at risk, at the first prenatal visit and in the third trimester. HIV – Screen all pregnant members. Routinely test males and females at high risk. Advise about risk factors for HIV infection. Other Laboratory Testing – Obtain other laboratory tests according to the member’s risk, the provider's professional judgment, and applicable state requirements for newborn screening tests. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule * Page W-6 All Provider Manuals Transmittal Letter ALL-155 Date 12/31/07 This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Z. EPSDT/PPHSD Screening Services Codes Page Z-1 All Provider Manuals Transmittal Letter All-155 Date 12/31/07 The following services are payable according to 130 CMR 450.146 through 450.150 in addition to the initial, periodic, or interperiodic Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) visit when they are performed and interpreted in the office of the provider who furnished the visit. Service Code Service Description Laboratory Services 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non- automated, with microscopy 81002 non-automated, without microscopy 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) 86580 Skin test, tuberculosis, intradermal 87081 Culture, presumptive, pathogenic organisms, screening only 87210 Smear, primary source, with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps) Audiometric Hearing Function Tests 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92587 Evoked otoacoustic emissions, limited (single stimulus level, either transient or distortion products) Behavioral Health Screening 96110 Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report Vision Tests 99173 Screening test of visual acuity, quantitative, bilateral This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Z. EPSDT/PPHSD Screening Services Codes Page Z-2 All Provider Manuals Transmittal Letter All-155 Date 12/31/07 This page is reserved.