Growing Up With Gateway^SM

• General Information
• Service Delivery Requirements Under HealthChoices
• Growing Up With Gateway^SM Unit
• Claim Filing
• Authorization
• Required Screens and Tests
• Detail of Screens and Tests
• Family and Medical History
• Height
• Weight
• Head Circumference
• Physical Growth/Nutritional Status
• Blood Pressure
• Dental Screening
• Vision Testing
• Hearing Screening
• Developmental/Behavior Appraisal
• Anemia Screening
• Sickle Cell
• Tuberculin Test
• Albumin and Sugar
• Blood Lead Level Screening
• Environmental Investigation
• Sexually Transmitted Disease Screening and Pap Tests
• Bacteriuria
• Immunizations

Gateway's Growing Up With Gateway^SM (GUWG) Program is based upon the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program for Medical Assistance eligible children under the age of 21 years.  Through the EPSDT Program, children are eligible to receive regular medical, dental, vision, and hearing screens to ensure that they receive all medically necessary services, without regard to Medical Assistance covered services.

Each Gateway primary care practitioner and primary care/specialist is responsible for providing the health screens for Gateway members, and reporting the results of the screens to Gateway, as well as communicating demographic information (e.g. telephone number, address, alternate address) with the EPSDT Coordinator to assist with scheduling, locating and addressing compliance issues.  Gateway verifies that primary care practitioners and PCP/Specialists for special needs are able to provide EPSDT services at the time of the practitioner's office site visit. 

Primary care practitioners that treat children under the age of 21 that are unable to comply with the requirements of the EPSDT Program must make arrangements for EPSDT screens to be performed elsewhere.  Alternative primary care practitioners and specialists should forward a copy of the completed progress report to the primary care practitioner so it can be placed in the member's chart.

The Preventive Health Department at Gateway is developing a School Partnership Initiative as a strategy to reach students who fall behind with recommended immunizations and check ups.  It is an ongoing initiative.  Gateway has established contacts with school nurses and are exploring opportunities for collaboration such as providing educational materials, participating in health fairs and meetings to achieve our objectives.

For further information regarding this initiative, please call the Preventive Health Department at 1-800-642-3550, option 2.

Primary care practitioners are required to ensure all children under the age of 21 have timely access to EPSDT services, and are responsible for assuring continued coordination of care for all members due to receive EPSDT services.  Also, primary care practitioners are to arrange for medically necessary follow-up care after a screen or an encounter.

The required screens and tests are outlined later in this section.  Primary care practitioners are required to follow this schedule to determine when the necessary screens and tests are to be performed.  Members must receive, at a minimum, eight screens between the ages of birth and 18 months, and seventeen screens between 19 months and 21 years.

When treating SSI and SSI-related members under the age of 21, an initial assessment must be conducted at the first appointment.  Written assessment must be discussed with the member's family or custodial agency, grievance or appeal rights must be presented by the primary care practitioner, and recommendations regarding case management must be documented.

Primary care practitioners are responsible for ongoing coordination and monitoring of care provided by other practitioners.

Gateway's Growing Up With Gateway (GUWG) staff works collaboratively with the Special Needs Case Management Unit (SN-CMU) in coordinating medically necessary services to members. GUWG staff provides outreach via telephone, mail, or home visitation when required, to members who are under 21 to provide education and assistance with scheduling appointments, transportation, and other issues that prevent access to healthcare.  GUWG staff is available to outreach to members identified by the primary care practitioner offices who are delayed with screens and/or immunizations or who are noncompliant with appointments.

The primary care practitioner is responsible for contacting new members identified on encounter lists as not complying with EPSDT periodicity and immunization schedules.  The GUWG contact person is an EPSDT Coordinator who can be reached at 1-800-642-3550, Option 4.

Gateway requires all EPSDT screens be submitted on a CMS-1500 or UB-92.

Codes for services must be included on the form. A description of the services will not be accepted. The practitioner's tax identification number must be included on the form to avoid problems with payment of services. Gateway does not apply coordination of benefits to EPSDT screens. Gateway considers a screen complete when a code for each service required for that age is checked. Completed forms should be submitted within sixty (60) days of the date of service to: Gateway Health Plan, Claims Processing Department, P.O. Box 11-718, Albany, NY 12211-0718.

Please refer to the Claims and Billing Section of this Manual for additional information regarding submission of claims for EPSDT visits.

If a member needs to be referred for specialty care as a result of an EPSDT screening, a standard Gateway referral must be issued by the primary care practitioner. 

Hospital admissions, outpatient surgical procedures, and certain other tests and services require authorization from the Utilization Management Department.

Primary care practitioners are required to refer members under the age of 21 with elevated blood levels and very low birth weight babies to CONNECT at 1-800-692-7288.

Members under age 21 who require behavioral health services should be referred to the appropriate BH-MCO serving the member's county of residence.

Please utilize the Gateway Guidelines for Children's Health Maintenance for documentation needed for the medical record.  Gateway has updated the Children's Health Maintenance Schedule based on the changes by the Department of Public Welfare to the periodicity schedule.  Please reference these updated guidelines on the Gateway website at www.gatewayhealthplan.com or refer to your Quality Improvement Manual.   Also, refer to the Children's Health Maintenance Schedule for frequency of testing and for further clarification.

Please complete and mail to Gateway the EPSDT Follow-up Form, located in the Forms and Reference Material Section of this Manual, for any members with abnormal findings, or who did not show up for his/her appointment, so Gateway may contact the member.

The CMS-1500 or UB 92 Form does not indicate findings from the clinical exam. It is the responsibility of the primary care practitioner to document these findings in the medical record.

Individuals Birth Through 3 Years

1. Record of a health history from parent or guardian
2. Unclothed physical examination
3. Developmental appraisal-Denver Test or equivalent
4. Growth Measurement
5. Metabolic Screening-PKU
6. Anemia Screening -Hemoglobin and/or Hematocrit
7. Lead Poisoning Evaluation
8. Urine Screen for Bacteria, Sugar, Albumin (age 2-6)
9. Sickle Cell Testing
10. Tuberculosis Testing
11. Assessing and Updating Appropriate Immunizations
12. Dental Screening
13. Nutritional Assessment

The initial EPSDT screen shall be the newborn physical examination in the hospital provided that the newborn physical examination contains all of the EPSDT screening components.

Individuals 3 Years Through Age 20

1. Record of a Health History from Parent or Guardian
2. Unclothed physical examination, including Tanner score and blood pressure
3. Developmental Appraisal
4. Vision Test
5. Hearing Test
6. Dental Examination
7. Malnutrition Evaluation
8. Tuberculosis Testing
9. Iron Anemia-Hemoglobin and Hematocrit
10. Lead Poisoning Evaluation (mandatory until age 6)
11. Sickle Cell Testing
12. Assessing and Updating Appropriate Immunizations
13. Nutritional Assessment
14. STD Screening and Pap Smear

It is the responsibility of each practitioner to obtain a Family and Medical History as part of the initial well-child examination.  The following Family and Medical History categories must be covered by the practitioner.

Family History

1. Hereditary Disorders, including Sickle Cell Anemia
2. Hay Fever-Eczema-Asthma
3. Congenital Malformation
4. Malignancy-Leukemia
5. Convulsions-Epilepsy
6. Tuberculosis
7. Neuromuscular Disease
8. Mental Retardation
9. Mental Illness in Parent Requiring Hospitalization
10. Heart Disease
11. Details of the Pregnancy, Birth and Neonatal Period
12. Complication of Pregnancy
13. Complication of Labor and Delivery
14. Birth Weight Inappropriate for Gestational Age
15. Neonatal Illness

1. Allergies, Asthma, Eczema, Hay Fever
2. Diabetes
3. Epilepsy or Convulsions
4. Exposure to Tuberculosis
5. Heart Disease or Rheumatic Fever
6. Kidney or Bladder Problems
7. Neurologic Disorders
8. Behavioral Disorders
9. Orthopedic Problems
10. Poisoning
11. Accidents
12. Hospitals/Operations
13. Menstrual History
14. Medication

Height must be measured on every child at every well-child visit.  Infants and small children must be measured in the recumbent position, and older children standing erect.   The height should be recorded in the child's medical record and should be compared to a table of norms for age.  The child's height percentile must be entered into the medical record.  Further study or referral is indicated in a child who has deviated from his/her usual percentile rank (determined by comparison with graphed previous measurements), or in a child whose single measurement exceeds two standard deviations from the norm for his/her age (beyond the 97^th or below the 3^rd percentile).

Weight must be measured on every child at every well-child visit.  Infants should be weighed with no clothes on, small children with just underwear, and older children and adolescents with ordinary house clothes (no jackets or sweaters) and no shoes.  The weight must be recorded in the child's medical record, and should be compared to a table of norms for age.  The child's weight percentile must also be entered into the medical record.  Further study or referral is indicated for a child who has deviated from his usual percentile rank (determined by comparison with graphed previous measurements), or when a child whose single measurement exceeds two standard deviations from the norm for his/her age (beyond the 97^th percentile or below the 3^rd percentile).

Head circumference should be measured at every well-child visit on infants and children up to the age of two years.  Measurements may be done with cloth, steel, or disposable paper tapes.  The tape is applied around the head from the supraorbital ridges anteriorly, to the point posteriorly giving the maximum circumference (usually the external protuberance).  Further study or referral is indicated for the same situations described in height and weight, and findings must be recorded in the child's medical record.

The child's height and weight are measured at each scheduled well-child exam.  In addition, if the child is less than two, the head circumference is also measured.  If the child's rate of growth falls either below the lower level of normal or above the upper level of normal, nutritional counseling to the parent is required if no organic cause for the growth deviation is found.

Blood pressure must be done at every visit for all children over the age of three years, and must be done with an appropriately sized pediatric cuff.  It may also be done under the age of three years when deemed appropriate by the attending practitioner.  Findings must be recorded in the child's medical record.

A dental assessment at every well-child visit, through observation, should be conducted up to age three years.  The child should be referred to a dentist by age three and should see the dentist every six months.  The dentist must check for the following and initiate treatment or refer as necessary.

• Caries
• Fillings Present
• Missing Teeth (permanent)
• Oral Infection

Documentation must be recorded in the child's medical record.

The chart should be affixed to a light-colored wall, with adequate lighting (10-30 foot candles) and no shadows.  Ordinary room lighting typically does not provide adequate lighting and the chart will need a light of its own.  The 20-foot line on the chart should be set at approximately the level of the eyes of a six-year-old.  Placement of the child must be exactly 20 feet.  Sites that do not have a 20-foot distance at which to test should obtain a 10-foot Snellen chart rather than convert the 20-foot chart.  The eye not being tested must be covered with an opaque occluder; several commercial varieties are available at minimal cost, or the practitioner may improvise one, but the hand may not be used, as it leads to inaccuracies.  In older children who seem to have difficulty or in young children, bring the child up to the chart (preferably before testing) and explain the procedure.

For screening, the tester should start with the big E (20-foot line) and then proceed down rapidly line-by-line, as long as the child reads one letter per line, until the child cannot read.  At this critical level, the child is tested on every letter on that line or adjacent line.  Passing is reading a majority of letters in a line.  It is not necessary to test for every letter on the chart.  Tests for hyperopia may be done but are not required.

Referral System

Children seven years of age and over must be referred if vision in either eye is 20/30 or worse.  A child may be referred if the parent complains or if the doctor discovers a medical reason.  (Generally, sitting close to the television without other complaints, and with normal acuity, is not a reason for referral.)  Children failing a test for hyperopia may be referred.

Children already wearing glasses must be tested with their glasses.  If they pass, record the measurement; nothing further needs to be done.  If they fail, refer for re-evaluation to a Gateway participating specialist, preferably to the vision practitioner who prescribed the lenses, regardless of when they were prescribed.

If the practitioner is unable to render an eye examination in a child nine years of age or older, because of the child's inability to read the chart or follow directions (e.g. a developmentally challenged child), refer this child to a participating ophthalmologist or optometrist.

Sweep audiometry is the most frequently used examination and must be administered to every screened child within the first month of life, and after the age of three through a hearing test.

Tuning forks and un-calibrated noisemakers are not acceptable for hearing testing.

For children under five years of age, observation should be made of the child's reaction to noises and to voices, unless the child is sufficiently cooperative to actually do the audiometry.  For audiometry, explain the procedure to the child.  For small children, present it as a game.  Present one tone loud enough for the child to hear, and explain that when it is heard, the child should raise his/her hand and keep it raised until the sound disappears.  Once the child understands, proceed with the test.  Doing one ear at a time, set the decibel level at 25, and testing at 500 HZ.  Then go successively to 1,000, 4,000, and 6,000.  Repeat for the other ear.  The quietest room at the site must be used for testing hearing.

Referral System

Any cooperative child failing sweep audiometry at any two frequencies must be referred.  If a child fails one tone, retest that tone with threshold audiometry to be certain it is not a severe single loss.  To be certain of the need for referral, the practitioner must immediately retest all failed tones by threshold audiometry, or, if there is question about the child's cooperation or ability at the time of testing, bring the child back for another sweep audiometry before referring.

Please remember that audiometers must be periodically (at least annually) calibrated for accuracy.

Since children with slow development and abnormal behavior may be able to be successfully treated if treatment is begun early, it is important to identify these problems as early as possible.  Questions must be included in the history, which relate to behavior and social activity as well as development.  Close observation is also needed during the entire visit for clues to deviations in those areas.

If the practitioner suspects developmental delay he/she is required to refer the child to CONNECT at 1-800-692-7288, for appropriate eligibility determination for early intervention services.

Below Five Years of Age

In addition to history and observation, a developmental evaluation is required.  In children who are regular patients of the practitioner site, this may consist of ongoing recording in the child's chart of developmental milestones sufficient to make a judgment on developmental progress.  In absence of this, the site may elect to conduct a Denver Developmental Screening Test as its evaluation utilizing the Denver II Form.

Marked slowness in any area is cause for a referral to a participating specialist, e.g. developmental center, a MH/MR agency, a developmental specialist, a pediatric neurologist or a psychologist.  If only moderate deficiencies in one or more areas are found, the practitioner must retest the child in 30-60 days.

Social Activity/Behavior

Questions should be asked to determine how the child relates to his family and peers and whether any noticeable deviation in any of his/her behavior exists.  The DASE test may be used as an evaluation.

Five Years and Older

Since the usual developmental tests are not valid at this age, observation and history must be used to determine the child's normality in the areas listed below.  Each child should be checked and recorded appropriately.  Major difficulty in any one area, or minor difficulty in two or more areas, is cause for referral to a participating mental health professional for further diagnosis.

1. Social Activity/Behavior-Does the child relate with family, teachers, and peers appropriately?  Has the child had a change in behavior, specifically a loss of interest in usual and preferred activities?
2. School-Is the child's grade level appropriate for his/her age?  Has the child been held back in school?  Has the child demonstrated a decrease in academic work, social function, and/or sports?
3. Peer Relationships
4. Physical/Athletic Dexterity
5. Sexual Maturation-Tanner Score.  A full explanation of Tanner observations and scoring is found below.
6. Speech-DASE Test if there is a problem in this area, record accordingly, refer appropriately.

TANNER SCORE

Knowing the normalcy of sexual development and being able to describe them with some understanding is the only way of assessing the abnormal.  Using a system, such as the Tanner Score, is the only way clinically of communicating from practitioner to practitioner or measuring change from time to time.  An accurate description of the sexual maturation process aids greatly in assessing height, growth patterns and prognosis, as well as future genital and reproductive development.

Standards for Genitalia Maturity Ratings for Males

Breast Development Standards for Females

Pubic Hair Development Standards for Males and Females

Anemia Screening

A hemoglobin or hematocrit must be done between 9-11 months of age and for females once after the onset of menses.  Subsequent testing should be at the practitioner's discretion, and based on the member's history and presenting complaints.

All premature or low-birth weight infants must have hemoglobin or hematocrit done on their first well-visit and then repeated according to the schedule later in this section.  The results of the test must be entered in the child's medical record.

Diagnosis of anemia should be based on the doctor's evaluation of the child and the blood test.  It is strongly suggested that a child with 10 grams of hemoglobin or less (or a hematocrit of 30% or less) be further evaluated for anemia.  However, even though 10 grams may represent the lower limit of normal for most of childhood, it should be realized that in early infancy and adolescence these levels should be higher.  For those practitioners who use charts to evaluate hemoglobin/hematocrit values, age is not used to determine the level of anemia, but rather values that fall two standard deviations below the mean.

Sickle Cell
A sickle cell test must be performed if indicated by history and/or symptoms.

Although the incidence of tuberculosis is decreasing, it now may constitute a significant health problem in some high-risk communities, especially in the lower socioeconomic groups.  Early recognition of the primary conveyor will permit:

• Prompt and cost effective treatment of cases
• Earlier detection of source cases of these patients for public health purposes

Children should be screened by using a Mantoux Test or multiple puncture skin test (Tine, Heaf, Mono-Vacc, Aplitest) commonly used by the primary care practitioner's office.  Any child with a positive tuberculin test must be further evaluated.

It is the responsibility of the primary care practitioner's office to secure the results of the tuberculin tests 48-96 hours after it has been administered.  Tuberculosis screening should be performed at the practitioner's discretion.

Tests for urinary albumin and sugar must be done at 5 years of age.  Dipsticks are acceptable.  A positive test must be followed up or referred for further care.  A 1+ albumin (or trace) with no symptoms need not be referred, as it is not an unusual finding.

The incidence of asymptomatic Undue Lead Absorption in children 6 months to 6 years of age is much higher than generally anticipated.  Therefore, it is required that the practitioner test the child for elevated lead levels.

All child healthcare practitioners are required to use a blood lead test to screen children at ages one and two, and children 36-72 months of age who have not previously been screened.  All children who receive Medical Assistance are considered at risk; therefore, all Gateway children between 36-72 months should be screened if not previously screened.  Please refer to the Child Health Maintenance Schedule for further clarification.

The Center for Disease Control requires the use of the blood lead test when screening children for lead poisoning.  A blood lead screening should be done by a blood lead measurement of either a venous or capillary (finger stick) blood specimen.

Recommended Follow-up Services For Children With Elevated Diagnostic* Blood Lead Levels

*A diagnostic Blood Lead Level is the first venous blood lead level obtained within 6 months of an elevated screening blood lead level.  A follow-up test is a venous blood lead level used to monitor the status of a child with an elevated diagnostic blood lead level test.

Timetable for Confirming Capillary Blood Lead Results with a Venous Blood Lead Measurement

*The higher the screening blood lead level, the more urgent the need for a diagnostic test.

Environmental Investigation

Environmental investigation as required by EPSDT and the 1991 Center for Disease Control Prevention of Lead Poisoning Guidelines and Abatement of Lead Sources are to be referred to the appropriate entity funded for this task.  (Allegheny County's Health Department at 412-687-2243 for Western Pennsylvania; and for Central Pennsylvania 1-800-440-LEAD.)  Gateway will update all policies and procedures associated with lead testing and environmental investigation according to any changes in future Center for Disease Control guidelines.

Use the Gateway EPSDT Follow-up Form, found in the Forms and Reference Materials Section of this Manual, to notify Gateway's EPSDT Coordinator of the need for follow-up.  Gateway can also assist with issues regarding elevated blood lead levels or regarding non-compliance.

• If the screening indicates the need for the member to be referred to a specialist, a Gateway referral form must be completed.

• Blood Lead tests must go either to your capitated laboratory or to Kirby Health Center.  When using Kirby Health Center, blood lead samples only will be processed, and a Gateway Lead Analysis Form must be completed.  Supplies for submitting to Kirby may be requested through Kirby Health Center by calling 1-888-841-6699.

Sexually Transmitted Disease Screening and Pap Tests

Tests and counseling are to be performed if sexually active.  Adolescents must be questioned about sexual activity and given assistance, diagnosis, treatment and information, as the situation requires.  Pelvic exams, including breast exams and pap tests, must be done annually when sexually active or at age 18.  Chlamydia screening should be performed annually if sexually active.

Bacteriuria

Test for bacteriuria must be conducted on any child who has symptoms relating to possible urinary tract involvement.  Routinely at every screen the simple Nitrate Test by dipstick is acceptable for bacteriuria testing.  Although it is best done on a first morning specimen, it may be completed on a random specimen.  A single dipstick is available to test for albumin, sugar and bacteria.

Immunizations

Both state and federal regulations require that immunizations be brought up to date during health screens and any other visits the child makes to the office.  The importance of assessing the correct immunization status cannot be overly stressed.  In all instances, the practitioner's records must show immunization history and documentation must include the date of the immunization, the signature of the person administering the immunization, and the name and lot number of the antigen.  This will provide the necessary basis for further visits and immunizations.

Gateway follows recommended childhood immunization schedules approved by the Advisory Commission on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians.  To facilitate distribution of the most current version of this schedule, it has been added to Gateway's website.  A paper copy is available upon request.  For a paper copy, please contact the Provider Servicing Department at 1-800-392-1145.