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Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services
EPSDT services are the current Denti-Cal Program's scope of benefits for beneficiaries under the age of 21. EPSDT was further defined by
federal law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) and includes dental services. In addition, Section 1905(4)(5) of the Social
Security Act requires that a medically necessary health care service listed in Section 1905(a) be provided to an EPSDT beneficiary even if the service is not
under a state's Medicaid plan to the rest of the Medicaid population.
The Department established regulations, effective on April 4, 1994, and amended effective April 27, 1995, to clarify the Department's implementation of the EPSDT program within Medi-Cal. The applicable regulations, contained within Title 22 of the California Code of Regulations, are Sections 51184, 51242, 51304, 51340, 51340.1 and 51532.
EPSDT: Frequently Asked Questions
What is EPSDT?
The early and periodic screening, diagnosis, and treatment (EPSDT) program is a special process within Denti-Cal specifically for children. Under federal law, EPSDT services are provided to any Medicaid beneficiary under age 21. For the Denti-Cal Program, this means medically necessary dental services provided for any Denti-Cal beneficiary who has not yet reached his or her 21st birthday are EPSDT services.
What kind of Dental Services are classified as EPSDT?
Whenever a Denti-Cal provider completes an oral examination on a child, an EPSDT screening service (and diagnostic service) has occurred. Any subsequent dental treatment resulting from that examination is considered an EPSDT dental service if the dental procedure is published in the Denti-Cal Manual of Criteria.
Early and Periodic Screening, Diagnosis, and Treatment Supplemental Services (EPSDT-SS)
EPSDT beneficiaries may require dental services that are not part of the current Denti-Cal program of benefits. Conversely, the dental service may be part of the Denti-Cal Program scope of benefits for adults but not for children or the dental provider may want to provide the service at a frequency or periodicity greater than currently allowed by the Denti-Cal Program. In these cases, such dental services are called EPSDT Supplemental Services (EPSDT-SS).
What is an EPSDT Supplemental Service?
Medi-Cal enrolled children may need dental services that are not part of the scope of benefits found within the Manual of Criteria. Denti-Cal covers these services, too. In California, these services are called EPSDT Supplemental Services or "EPSDT-SS."
Example 1: John S. has a craniofacial anomaly with multiple edentulous areas. The edentulous areas cannot be adequately restored using conventional prosthetics - an implant-retained fixed prosthesis may be authorized as an EPSDT Supplemental Service.
EPSDT-SS also covers situations when the dental service being requested may be listed in the Manual of Criteria, but the child does not meet the published criteria.
Example 2: Cindy T. (age 10) suffers from aggressive periodontitis and requires periodontal scaling and root planing. The Manual of Criteria, however, states this procedure is not a benefit for patients under 13 years of age. The medically necessary periodontal procedures may be authorized as EPSDT Supplemental Services.
Example 3: Alicia M. (age 12) has fractured an anterior tooth in an accident. Although only three surfaces were involved in the traumatic destruction, the extent is such that a bonded restoration will not be retentive. With adequate supplemental documentation (in this case, intraoral photographs of the fractured tooth) and narrative explanation by the dentist, a prefabricated or laboratory-processed crown may be authorized as an EPSDT Supplemental Service.
Example 4: Andre S. does not qualify for orthodontic services per the handicapping malocclusion criteria (he scores below 26 points on the HLD Index Score Sheet or does not have one of the five automatic qualifying conditions). However, a speech pathologist has determined that his malocclusion is a prime etiologic factor in his speech pathosis - resolution cannot be achieved unless his malocclusion is corrected. In this case, orthodontics may be authorized as an EPSDT Supplemental Service.
When Would I Request an EPSDT Supplemental Service for My Child Patients?
You would request prior authorization for an EPSDT Supplemental Service under any one of the following conditions:
- To perform a medically necessary dental procedure that is not listed in the current Manual of Criteria.
- To perform a medically necessary dental procedure that is listed in the current Manual of Criteria when the child does not meet the published criteria.
- The child needs a dental service more frequently than is currently allowed under Program criteria.
How Do I Request an EPSDT Supplemental Service?
All EPSDT Supplemental Services must be prior authorized and you MUST print "EPSDT Supplemental Services Request" in Field 34 of the TAR/Claim form. If the requested dental service is not listed within the Manual of Criteria, use the appropriate unspecified procedure code and fully describe the service. Do not limit your comments to Field 34 of the TAR/Claim form - attach all documents that are needed to describe the requested services.
What Kind of Clinical Information Does the Program Need to Determine the Medical Necessity?
At a minimum, you should address the following:
- Diagnosis of the dental condition
- Any overall health issues and medical conditions
- Prognosis with and without the requested treatment
- Clinical rationale for why a covered benefit or lower-cost service will not suffice (you are encouraged to include copies of published clinical studies or
articles from peer-reviewed, professional dental journals to support your rationale).
Note: Documentation can be narrative, radiographic, photographic, or copies of any relevant documents (including diagnostic imaging).
In some cases, the dental services are necessary to resolve or improve an associated medical condition. For example, a child's speech therapist determines that a diagnosed speech pathosis cannot be resolved without dental treatment. A consultation letter from the speech therapist should be included with the EPSDT Supplemental Services TAR/Claim.
It is virtually impossible to submit too much documentation with your TAR for EPSDT Supplemental Services!
Whom Can I Call to Obtain Further Information About the EPSDT and EPSDT-SS Requirements Under Denti-Cal?
Denti-Cal Telephone Service Center Representatives are available toll-free, (800) 423-0507, to answer all of your questions regarding EPSDT services and EPSDT Supplemental Services.
EPSDT-SS Requests for Orthodontic Services
All EPSDT-SS requests for orthodontic services must include a completed Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet (DC-016) in addition to the aforementioned documentation requirements. The review of active orthodontic services also requires the submission of diagnostic casts.
For detailed instructions on how to complete the HLD Index, refer to the Forms section of the Handbook.