N.C. Medicaid Clinical Coverage Policy No. 3D § 2.2.1

a. 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal

Medicaid requirement that requires the state Medicaid agency to cover

services, products, or procedures for Medicaid beneficiary under 21 years of

age if the service is medically necessary health care to correct or ameliorate

a defect, physical or mental illness, or a condition [health problem] identified

through a screening examination (includes any evaluation by a physician or

other licensed practitioner).

This means EPSDT covers most of the medical or remedial care a child needs

to improve or maintain his or her health in the best condition possible,

compensate for a health problem, prevent it from worsening, or prevent the

development of additional health problems.

Medically necessary services will be provided in the most economic mode, as

long as the treatment made available is similarly efficacious to the service

requested by the beneficiary’s physician, therapist, or other licensed

practitioner; the determination process does not delay the delivery of the

needed service; and the determination does not limit the beneficiary’s right to

a free choice of providers.

EPSDT does not require the state Medicaid agency to provide any service,

product, or procedure:

1. that is unsafe, ineffective, or experimental or investigational.

2. that is not medical in nature or not generally recognized as an accepted

method of medical practice or treatment.

Service limitations on scope, amount, duration, frequency, location of service,

and other specific criteria described in clinical coverage policies may be

exceeded or may not apply as long as the provider’s documentation shows that

the requested service is medically necessary “to correct or ameliorate a defect,

physical or mental illness, or a condition” [health problem]; that is, provider

documentation shows how the service, product, or procedure meets all EPSDT

criteria, including to correct or improve or maintain the beneficiary’s health in

the best condition possible, compensate for a health problem, prevent it from

worsening, or prevent the development of additional health problems.

b. EPSDT and Prior Approval Requirements

1. If the service, product, or procedure requires prior approval, the fact that

the beneficiary is under 21 years of age does NOT eliminate the

requirement for prior approval.

2. IMPORTANT ADDITIONAL INFORMATION about EPSDT and

prior approval is found in the NCTracks Provider Claims and Billing

Assistance Guide, and on the EPSDT provider page. The Web addresses

are specified below.

NCTracks Provider Claims and Billing Assistance Guide:

https://www.nctracks.nc.gov/content/public/providers/providermanuals.ht

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EPSDT provider page: https://medicaid.ncdhhs.gov/