Wis. Admin. Code Department of Health Services DHS 105.37 - Early and periodic screening, diagnosis and treatment (EPSDT) providers

(1) EPSDT HEALTH ASSESSMENT AND EVALUATION SERVICES.

(a) Eligible providers. The following providers are eligible for certification as providers of EPSDT health assessment and evaluation services:

1. Physicians;

2. Outpatient hospital facilities;

3. Health maintenance organizations;

4. Visiting nurse associations;

5. Clinics operated under a physician's supervision;

6. Local public health agencies;

7. Home health agencies;

8. Rural health clinics;

9. Indian health agencies; and

10. Neighborhood health centers.

(b) Procedures and personnel requirements.

1. EPSDT providers shall provide periodic comprehensive child health assessments and evaluations of the general health, growth, development and nutritional status of infants, children and youth. Immunizations shall be administered at the time of the screening if determined medically necessary and appropriate. The results of a health assessment and evaluation shall be explained to the recipient's parent or guardian and to the recipient if appropriate.

2. EPSDT health assessment and evaluation services shall be delivered under the supervision of skilled medical personnel. In this section "skilled medical personnel" means physicians, physician assistants, nurse practitioners, public health nurses or registered nurses. Skilled medical personnel who perform physical assessment screening procedures shall have successfully completed either a formal pediatric assessment or an inservice training course on physical assessments approved by the department. Individual procedures may be completed by paraprofessional staff who are supervised by skilled medical personnel. Registered nurses who perform EPSDT physical assessments shall have satisfactorily completed a curriculum for pediatric physical assessments approved by the department.

3. All conditions uncovered which warrant further care shall be diagnosed or treated or both by the provider, if appropriate, or referred to other appropriate providers. A referral may either be a direct referral to the appropriate health care provider or a referral recommendation submitted through the agency responsible for the patient's case management and advocacy.

4. Health maintenance organizations and prepaid health plans providing EPSDT services shall meet all requirements of 42 CFR 441.60 in addition to the requirements under subds. 1. to 3.

(c) Records and documentation.

1. Certified providers of EPSDT screening services shall:

a. Complete the department's EPSDT claim form and an individual health and developmental history for each client; and

b. Maintain a file on each client receiving EPSDT services which includes a copy of the EPSDT claim form, individual health and developmental history and follow-up for necessary diagnosis and treatment services.

2. The EPSDT provider shall release information on the results of the health assessment to appropriate health care providers and health authorities when authorized by the patient or the patient's parent or guardian to do so.

(2) EPSDT CASE MANAGEMENT ACTIVITIES.

(a) Case management reimbursement. Providers certified under sub. (1) as providers of EPSDT health assessment and evaluation services shall be eligible to receive reimbursement for EPSDT case management in accordance with the limitations contained in the case management agreement between the provider and the department.

(b) Case management plan.

1. All EPSDT providers who apply to receive reimbursement for EPSDT case management services shall submit to the department a case management plan. The case management plan shall describe the geographic service area, target population, coordination with support activities conducted by the department and other health-related services, case management activities and the method of documenting the activities.

2. The department shall evaluate the adequacy of each provider's case management plan according to the case management requirements of the proposed service area and target population, the extent to which the plan would ensure that children receive the necessary diagnosis and treatment services for conditions detected during EPSDT health examinations, the proposed coordination with the EPSDT central notification system and other health related services, and proposed methods for documenting case management services. Based on the evaluation, the department shall either approve or deny the provider's request for reimbursement of case management activities and shall impose on providers as conditions for reimbursement any personnel, staffing or procedural requirements that it determines are necessary pursuant to 42 CFR 441 Part B.

(c) Records and documentations. Providers shall maintain records and documentation required by the department in order to verify appropriate use of funds provided by the department for EPSDT case management activities.

(3) DIAGNOSIS AND TREATMENT SERVICES. Providers of diagnosis and treatment services for EPSDT recipients shall be certified according to the appropriate provisions of this chapter.

Notes

Wis. Admin. Code Department of Health Services DHS 105.37

Cr. Register, February, 1986, No. 362, eff. 3-1-86.

For covered EPSDT services, see s. DHS 107.22.