All providers offering care to AHCCCS members under 21 years of age, shall use the AHCCCS EPSDT Clinical Sample Template to document age-specific, required information related to the EPSDT / Well-Child screenings and visits.
Alternatively – The provider’s Electronic Health Record may be used, so long as it includes ALL components present on the age-specific AHCCCS EPSDT form.
Timely submission of EPSDT/Well-Child visit forms is very important to member care coordination. Submitting the visit forms (or copy of suitable EHR equivalent) to the Health Plan soon after the well-child visit allows us to:
There are three easy ways to submit your EPSDT forms or EHRs after a visit.
CRS is a special designation for AHCCCS children under 21, with certain qualifying medical conditions.
CRS Members:
The Banner Health Plans (BHP) has CRS Liaisons dedicated to each MSIC location in our service area and work to streamline care.
If you are caring for a child with a potential CRS eligible condition, we can help prepare and submit applications and required supporting documents.
Send your CRS referrals and questions to [email protected].
Nutritional Assessment and Services for EPSDT-Aged Members are covered by Banner – University Family Care/ACC and Banner – University Family Care/ALTCS. Nutritional assessments, performed by the member's PCP, are covered during EPSDT/Well-Child visit screenings and on an inter-periodic basis when medically necessary. Registered dieticians can also provide nutritional assessments when ordered by the PCP, especially for underweight or overweight EPSDT members. Prior Authorization is not required for nutritional assessments by PCPs or registered dieticians.
Nutritional therapy is covered for EPSDT-aged members on an enteral, parenteral, or oral basis when medically necessary to meet daily dietary requirements or supplement nutritional intake. Prior Authorization is required for commercial oral nutritional supplements, enteral nutrition, or parenteral nutrition, except for certain circumstances such as when the member is already receiving enteral/parenteral nutrition or during the first 30 days of temporary oral supplemental feedings after an emergent hospitalization. A certificate of medical necessity is also required for commercial oral nutrition:
The Health Plan also covers nutritional therapy for WIC-eligible children with medical conditions, including necessary formulas not provided by WIC. Commercial oral nutritional supplements require medical necessity determination based on specific criteria outlined in [AMPM Policy 430 Early and Periodic Screening, Diagnostic, and Treatment Services]. Supporting documentation must accompany the Certificate of Medical Necessity, demonstrating compliance with criteria and including nutritional counseling, recent clinical notes, height/weight percentiles, and attempts to address nutritional concerns. Ongoing requests require follow-up documentation and assessment. Metabolic medical foods used to treat inherited metabolic disorders are covered as well, with specific requirements outlined in [AMPM Policy 310-GG, Section III., C. Metabolic Medical Foods].
BHP is dedicated to enhancing access to developmental screening and evaluation for AHCCCS members aged 0-3 years to capitalize on early developmental opportunities. PCPs are key in this process; during an EPSDT visit, they assess developmental status using specific screening tools and parental discussions. If developmental concerns arise, the PCP may guide parents and direct referrals to the Arizona Early Intervention Program (AzEIP) without the need for prior authorizations for in-network providers, although out-of-network providers require prior authorization along with medical documentation.
PCPs need to perform a thorough EPSDT physical exam adhering to the established schedule and document any referrals to AzEIP or specialists on the relevant forms, then submit these to the health plan for review. If required evaluations by AzEIP or specialists haven't been carried out, BHP's coordinator will liaise with necessary parties to ensure completion.
For EPSDT eligible children needing services, AzEIP conducts evaluations to ascertain eligibility, then collaborates with families to forge an Individual Family Service Plan (IFSP), pinpointing the child's current development level and required interventions, which must be promptly shared with BHP. BHP processes these requests efficiently and communicates the determinations of service necessity. If PCPs ascertain that certain services are not medically necessary, BHP informs all parties and issues a Notice of Adverse Benefit Determination.
In cases where children age out of AzEIP eligibility or do not qualify, BHP's Maternal Child Health department takes the baton, offering targeted outreach, care coordination, and facilitating connections with other resources like Raising Special Kids and AzEIP's Central Directory of Resources. Additionally, for children over 3, PCPs can refer to the District of Residence for further developmental assistance in line with AZ Child Find Requirements.
If you are needing assistance with AzEIP, please call Ricardo Medina, EPSDT Supervisor at 520-874-2697.