5160-14-04 Healthchek: reimbursement of early and periodic screening, diagnosis, and treatment (EPSDT) services.

(A) Healthchek (EPSDT) service codes.

(1) Healthchek (EPSDT) screening visits shall be billed using the appropriate preventive medicine services code.", reflecting a comprehensive preventive medicine evaluation and management, focusing on age and gender appropriate history, examination, anticipatory guidance, and risk factor reduction interventions. For new patients, codes are 99381 to 99385; for established patients, codes are 99391 through 99395.

(2) Providers of healthchek (EPSDT) screening visits shall include the following information when billing the department based on the date of service and type of claim submission.

(a) For dates of service prior to October 16, 2003 or the effective date of electronic data interchange transactions (e.g. the 837 professional transaction), indicate that the service is part of the healthchek (EPSDT) program by placing:

(i) An "E" in item 24h on the paper claim form or in the same block on an electronic claim indicating that a healthchek (EPSDT) visit was provided and no follow -up services were required; or

(ii) "An "R" in item 24h on the paper claim form or in the same block on an electronic claim indicating that a healthchek (EPSDT) visit was provided, follow-up is required, and a referral was made.

(b) For dates of service October 16, 2003 and after or the effective date of electronic data interchange transactions (e.g. the 837 professional transaction) and based on the type of claim submission, follow these instructions:

(i) When billing electronically using the 837 professional claim transaction, use the EPSDT referral feature in the 2300 claim information loop to indicate that the healthchek (EPSDT) referral was made by placing a "Y" in the "Yes/No" condition or response code data element and complete the condition indicator data element in the healthchek (EPSDT) referral feature area.

(ii) When using a paper claim form, follow the instructions provided in paragraphs (A)(2)(a)(i) and (A)(2)(a)(ii) of this rule, which require that item 24h on the paper claim form be completed.

(B) Reimbursement for diagnostic and treatment services.

(1) In addition to the healthchek (EPSDT) screening services, the department will reimburse providers for the following services provided during, or as part of, the healthchek (EPSDT) screening visit.

(a) Specimen collection and laboratory services in accordance with Chapter 5101:3-11 of the Administrative Code, although specimens sent to an outside laboratory for analysis must be billed by the laboratory that actually performs the procedure;

(b) Immunizations in accordance with rule 5101:3-4-12 of the Administrative Code;

(c) Formal developmental tests;

(d) Pure-tone audiometry and other formal hearing tests using calibrated electronic equipment;

(e) Tuberculin tests; and

(f) Other covered physician services in accordance with Chapter 5101:3-4 of the Administrative Code.

(2) Interperiodic examinations, vision, hearing, and dental services that are medically necessary to determine the existence of suspected physical or mental illnesses or conditions are covered under medicaid and may be billed in accordance with Chapters 5101:3-4, 5101:3-5, and 5101:3-6 of the Administrative Code.

(3) The services listed in paragraph (B)(1) of this rule are services that may be performed on the same day as the healthchek (EPSDT) screening visit or at another time as medically indicated or as necessary from a scheduling standpoint (e.g., a patient requires that an immunization service be administered in three months from the date of the screening service).

(a) These services may be provided by the provider who performed the healthchek (EPSDT) screening service or by another eligible provider under medicaid.

(b) Only the provider who performed the service may bill for the service.

(4) To receive separate reimbursement for these services, the provider must bill the department by itemizing the appropriate code in accordance with rule 5101:3-1-60 of the Administrative Code.

(C) Prior authorization and claim submission requirements for healthchek (EPSDT) services provided through the medicaid managed care program (MCP) are specified in rule 5101:3-26-05.1 of the Administrative Code.

Replaces: Part of 5101:3-14-06

Cite as Ohio Admin. Code 5160-14-04

Effective: 07/01/2006
R.C. 119.032 review dates: 11/10/2005 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 9/1/87, 2/17/91, 4/1/92 (Emer), 7/1/92, 8/1/01, 7/1/03