EPSDT SCREENING SERVICES

Important Notice Regarding billing for EPSDT screening services

• As required by the Department of Public Welfare, effective March 1, 2004, Gateway Health Plan^® will no longer accept the MA-517 form for EPSDT screenings.
• All EPSDT screening services should be submitted to Gateway either on a CMS-1500, UB-92 or the corresponding 837P or 837I format for EDI claims.
• All services that you previously submitted using the EPSDT MA-517 form can be submitted on the CMS-1500, UB-92 claim form or Electronic 837P or 837I format including vaccine administration fees.
• Gateway Health Plan^® considers a screen complete when codes from each service area required for that age including the appropriate evaluation and management codes, are documented on the CMS-1500, UB-92 or the corresponding 837P format for EDI screenings. *
• Gateway Health Plan’s EPSDT claims are not subject to Coordination of Benefits (COB).

Gateway Health Plan^® EPSDT screens must be billed as indicated below:

Paper CMS-1500 format:

• The national code for EPSDT screening (S0302) should be reported on the 1st line of the CMS-1500. FQHC and RHC providers must use S0302 as well. T1015 with modifier EP will not be accepted by Gateway Health Plan. Code S0302 is NOT a standalone code. Therefore, it MUST be used in conjunction with:
  • Age-appropriate procedure codes for evaluation and management services, including immunizations. Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
  • Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21. When applicable, you may enter up to three additional diagnosis codes. Please note that you are not required to use immunization diagnosis codes.
  • Report visit code ‘03’ in box 24(h) when providing EPSDT screening services.
  • Report 2-character EPSDT referral code for referrals made or needed as a result of the screen in box 10(d). Codes for referrals made or needed as a result of the screen are:
    YO – Other YV – Vision YH – Hearing
    YB – Behavioral YM – Medical YD – Dental
• With the exception of the dental component for clinics that do not offer dental services, FQHCs/RHCs may not bill for partial EPSDT screens.

Paper UB-92 format:

• The national code for EPSDT screening (S0302) should be reported on the 1st line of the UB-92. FQHC and RHC providers must use S0302 as well. T1015 with modifier EP will not be accepted by Gateway Health Plan. Code S0302 is NOT a standalone code. Therefore, it MUST be used in conjunction with:
  • Age-appropriate procedure codes for evaluation and management services, including immunizations Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
  • Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21. When applicable, you may enter up to three additional diagnosis codes. Please note that you are not required to use immunization diagnosis codes.
  • Report Condition Code “A1” in block 24
  • Report 2-character EPSDT referral code for referrals made or needed as a result of the screen in block 57. Codes for referrals made or needed as a result of the screen are:
    

    YO – Other	YV – Vision	YH – Hearing
    YB – Behavioral	YM – Medical	YD – Dental

• Please note that both an appropriate procedure code and revenue code must be used on the UB-92.

Electronic 837P format:

• The national code for EPSDT screening (S0302) should be reported as the first procedure code. FQHC and RHC providers must use S0302 as well. T1015 with modifier EP will not be accepted by Gateway Health Plan. Code S0302 is NOT a standalone code. Therefore, it MUST be used in conjunction with:
  • Age-appropriate procedure codes for evaluation and management services, including immunizations Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
  • Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21. When applicable, you may enter up to three additional diagnosis codes. Please note that you are not required to use immunization diagnosis codes.
• Populate the SV111 of the 2400 loop with a “yes” for an EPSDT claim (this is a mandatory federal requirement)
• Populate the Data Element CLM12 in the 2300 Claim Information Loop with “01” (meaning EPSDT)- (revised by EPSDT Billing Update 2/24/04)
• Populate NTE01 of the NTE segment with “ADD”. This means that additional information is available in ‘field’ NTE02 (see below).
• Populate NTE02 of the NTE segment of the 2300 Claim Information Loop with appropriate referral codes:
  

  YO – Other	YV – Vision	YH – Hearing
  YB – Behavioral	YM – Medical	YD – Dental

For multiple claim notes, concatenate value into a single string (i.e., NTE*ADD*YOYVYH)

Electronic 837I format:

• The national code for EPSDT screening (S0302) should be reported as the first procedure code. FQHC and RHC providers must use S0302 as well. T1015 with modifier EP will not be accepted by Gateway Health Plan. Code S0302 is NOT a standalone code. Therefore, it MUST be used in conjunction with:

  • Age-appropriate procedure codes for evaluation and management services, including immunizations Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
  • Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21. When applicable, you may enter up to three additional diagnosis codes. Please note that you are not required to use immunization diagnosis codes.
• Populate the Data Element HI01 in the 2300 Claim Information Loop with qualifier "BG" (meaning Condition Code) and "A1"(revised by EPSDT Billing Update 3/8/04)
• Populate NTE01 of the NTE segment with “ADD”. This means that additional information is available in ‘field’ NTE02 (see below).
• Populate NTE02 of the NTE segment of the 2300 Claim Information Loop with appropriate referral codes:
  

  YO – Other	YV – Vision	YH – Hearing
  YB – Behavioral	YM – Medical	YD – Dental

Payment: Claims for S0302 will be paid at the provider’s EPSDT rate only if the appropriate codes for Management and Evaluation services are submitted.

* Please consult the Pennsylvania Children’s Checkup (EPSDT) Program Periodicity Schedule and Coding Matrix as well as the Recommended Childhood Immunization Schedule for screening eligibility information and the services required to bill for a complete EPSDT screen.

Note: The Periodicity Schedule and the Immunization Schedules are updated periodically. Please use the most recent schedules when providing EPSDT screens.

Additional details:

Effective 3/1/04 dates of service, Gateway Health Plan^®will reimburse EPSDT screens ONLY when billed with procedure code S0302 AND the appropriate codes for Evaluation and Management services. Claims without the E&M code will not be eligible for reimbursement.

The provider’s EPSDT rate will be paid for procedure code S0302. Providers must bill at least their contracted rate for this code in order for payment to be issued.

MA-517 forms received for dates of service after 2/29/04 will be denied and must be resubmitted on a CMS-1500 or UB-92 claim form within 90 days from the date of the denial remittance.

If you have any questions regarding Gateway’s EPSDT billing guidelines, please contact Provider Servicing at 1-800-392-1145.