PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MCUP3065 (previously UP100365)
Policy/Procedure Title: Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) Services
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
Original Date: 03/16/2005
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 02/18/2015
I.
RELATED POLICIES:
A. MCUP3041 TAR Review Process
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To define PHC’s responsibility to cover medically necessary services not covered under the Medi-Cal
Program for children under the age of 21 under the Early and Periodic Screening Diagnosis and Treatment
EPSDT supplemental services benefit.
VI.
POLICY / PROCEDURE:
A. For services to be approved by PHC under this section, services requested must satisfy the criteria in
Title 22, California Code of Regulation, Section 51340
B. EPSDT services shall be covered by PHC subject to prior authorization must meet the standards set forth
in Sections 51003 and 51303, and any specific requirements applicable to a specific service that are
based on the standards and requirements of those sections other than the service-specific requirements
set forth in Section 51340.1.
C. The service-specific requirements as set forth in Section 51340.1.and must meet all of the following
criteria, where applicable:
1. The services are necessary to correct or ameliorate defects in physical illnesses and mental illnesses
and conditions (Note: Mental illnesses and conditions are the responsibility of the local Mental
Health Department in the following counties: Marin, Napa, Yolo, Sonoma, Mendocino and are the
subcontracted to the local Health Department in Solano County).
2. The supplies, items, or equipment to be provided are medical in nature.
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Policy/Procedure Number: MCUP3065 (previously
Lead Department: Health Services
UP100365)
Policy/Procedure Title: Early and Periodic Screening, Diagnosis ☒ External Policy
and Treatment (EPSDT) Services
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 03/16/2005
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
3. The services are not requested solely for the convenience of the beneficiary, family, physician or
another provider of services.
4. The services are not unsafe for the individual EPSDT-eligible beneficiary, and are not experimental.
5. The services are neither primarily cosmetic in nature nor primarily for the purpose of improving the
beneficiary’s appearance. The correction of severe or disabling disfigurement shall not be
considered to be primarily cosmetic nor primarily for the purpose of improving the beneficiary’s
appearance.
6. Where alternative medically accepted modes of treatment are available, the services are the most
cost-effective.
D. In addition to the items listed under II, the services to be provided:
1. Must be generally accepted by the professional medical community as effective and proven
treatments for the conditions for which they are proposed to be used. Such acceptance shall be
demonstrated by scientific evidence, consisting of well designed and well conducted investigations
published in peer-review journals, and, when available, opinions and evaluations published by
national medical and dental organizations, consensus panels, and other technology evaluation
bodies. Such evidence shall demonstrate that the services can correct or ameliorate the conditions for
which they are prescribed.
2. Are within the authorized scope of practice of the provider, and are an appropriate mode of treatment
for the health condition of the beneficiary.
3. The predicted beneficial outcome of the services outweighs potential harmful effects.
4. Available scientific evidence demonstrates that the services improve the overall health outcomes as
much as, or more than, established alternatives.
E. Prior Authorization Process
1. For services to be considered under the EPSDT benefit a TAR must be submitted that states
explicitly that the request is for EPSDT supplemental services and shall be accompanied by the
following information:
a. The principal diagnosis and significant associated diagnoses.
b. Prognosis.
c. Date of onset of the illness or condition, and etiology if known.
d. Clinical significance or functional impairment caused by the illness or condition.
e. Specific types of services to be rendered by each discipline with physician's prescription where
applicable.
f. The therapeutic goals to be achieved by each discipline, and anticipated time for achievement of
goals.
g. The extent to which health care services have been previously provided to address the illness or
condition, and results demonstrated by prior care.
h. Any other documentation available which may assist the Department in making the
determinations required by this section.
2. The TAR will be reviewed by PHC using current EPSDT criteria.
VII.
REFERENCES:
A. Title 22, California Code of Regulation, Sections 51003/51184/ 51303/51340
VIII.
DISTRIBUTION:
A. Provider Manual
B. PHC Directors
Page 2 of 3
Policy/Procedure Number: MCUP3065 (previously
Lead Department: Health Services
UP100365)
Policy/Procedure Title: Early and Periodic Screening, Diagnosis ☒ External Policy
and Treatment (EPSDT) Services
☐ Internal Policy
Next Review Date: 02/18/2016
Original Date: 03/16/2005
Last Review Date: 02/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES: 10/18/06; 07/15/09; 01/18/12; 02/18/15
PREVIOUSLY APPLIED TO:
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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