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Early and Periodic Screening, Diagnostic, and Treatment

Early and Periodic Screening, Diagnostic, & Treatment (EPSDT) is a Medi-Cal benefit for individuals under the age of 21 who have full-scope Medi-Cal eligibility.  This benefit allows for periodic screenings to determine health care needs.  Based upon the identified health care need and diagnosis; treatment services are provided to correct or ameliorate defects and chronic conditions.  EPSDT services include all services covered by Medi-Cal.  In addition to the regular Medi-Cal benefits, a beneficiary under the age of 21 may receive additionally medically necessary services. 
 
In accordance with the requirements in Section 1905(r) of the Social Security Act and Title 42 Code of Federal Regulations (CFR) Section 441.50 et seq., the Department of Health Care Services (DHCS) is responsible for providing full-scope Medi-Cal beneficiaries under the age of 21 with a comprehensive, high-quality array of preventive (such as screening), diagnostic, and treatment services under EPSDT. These services are covered without cost.  

How Does One Request EPSDT Skilled Nursing Services?

For full scope fee-for-service Medi-Cal beneficiaries that do not have a California Children’s Services (CCS) eligible medical condition, the provider must submit a Treatment Authorization Request (TAR) for Pediatric Day Health Care (PDHC) and Private Duty Nursing (PDN) services.  For TAR information, refer to the TAR Overview section of the Medi-Cal Provider Manual.  In addition to the TAR, the provider must also submit the following medical documentation:
  • Plan of Treatment (POT) signed by a physician (within 30 days from initial start of care service date)
  • Nursing Assessment (within 30 days from initial start of care service date)
  • Medical information supporting the nursing services requested, i.e. medication record, discharge summary notes, and treatment notes
 

What if a CCS-Eligible Child is Enrolled in a Medi-Cal Managed Care Health Plan?

For beneficiaries enrolled in a Medi-Cal Managed Care Health Plan (MCP) who have a potential CCS-eligible medical condition, must fax a Service Authorization Request (SAR) to the beneficiaries’ local CCS County office or upload the SAR into the Provider Electronic Data Interchange (PEDI).
 
Providers in Alpine, Amador, Calaveras, Colusa, El Dorado, Glenn, Imperial, Inyo, Mariposa, Mono, Nevada, Plumas, San Benito, Sierra, Sutter, Tehama, Tuolumne and Yuba counties, must fax a SAR for Pediatric Day Health Care (PDHC) and PDN services to the Integrated Systems of Care Division (ISCD) Authorization Unit at (916) 440-5313 or upload the SAR into the PEDI.
 
For general SAR information, refer to the California Children’s Services (CCS) Program-Service Authorization Request (SAR) section of the Medi-Cal Provider Manual. In addition to the SAR, the provider must also submit the following medical documentation:
  • Plan of Treatment (POT) signed by a physician (within 30 days from initial start of care service date)
  • Nursing Assessment (within 30 days from initial start of care service date)
  • Medical information supporting the nursing services requested, i.e. medication record, discharge summary notes, and treatment notes

What if a CCS-Eligible Child is Enrolled in a Whole Child Model Medi-Cal Managed Care Health Plan?

For beneficiaries enrolled in a Whole Child Model (WCM) Medi-Cal Managed Care Health Plan (MCP), who have a CCS-eligible medical condition and are case managed by the WCM MCP, requests for authorization of PDN services will be referred to the MCP for review and authorization. 
The MCP is responsible for authorization of PDN services. Providers must submit the authorization request to the MCP for all the PDN services related to a CCS Program eligible medical condition. Providers shall submit the following medical documentation:
  • POT signed by a physician (within 30 days from initial start of care service date)
  • Nursing Assessment (within 30 days from initial start of care service date)
  • Medical information supporting the nursing services requested, i.e. medication record, discharge summary notes, and treatment notes
  • Other information, as specified by the MCP
 
The WCM program is to be implemented in 21 specified counties in three phases.  
 
WCM Medi-Cal Managed Care Health Plan
WCM Counties
Phase 1 – Implemented July 1, 2018
CenCal Health
San Luis Obispo, Santa Barbara
Central California Alliance for Health
Merced, Monterey, Santa Cruz
Health Plan of San Mateo
San Mateo
Phase 2 – Implemented January 1, 2019
Partnership Health Plan
Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Siskiyou, Shasta, Solano, Sonoma, Trinity, Yolo
Phase 3 – No Sooner than July, 1, 2019
CalOptima
Orange
 

Contact Information

For questions regarding the approved EPSDT in-home PDN/CHHA/PDHC hours for your child, or to report unresolved partial service or no service, please e-mail EPSDT@dhcs.ca.gov
 
For TAR related questions, email PDNinquiries@dhcs.ca.gov or call (800) 541-5555.
 
For SAR related questions, email CCSprogram@dhcs.ca.gov or call (916) 552-9105.
 
When emailing or leaving a message, please include your name, the name of the child, the child’s Medi-Cal number, and a phone number where we can contact you so that we may effectively respond to your request. 

Resources and Information

Last modified on: 3/28/2019 6:56 PM