Health Check and EPSDT Provider Information

Health Check and Early Periodic Screening, Diagnostic and Treatment (EPSDT)
Information for Consumers About Medicaid Services for Children

What are Health Check and EPSDT?

Health Check is Medicaid for children. Health Check covers complete medical and dental check-ups, and provides vision and hearing screenings and referrals for treatment.

Early Periodic Screening, Diagnostic and Treatment (EPSDT) is the federal law that requires Medicaid to provide medically necessary health care services to Medicaid-eligible children through the age of 20 even if the servcies are not normally covered by Medicaid or the services are normally only covered for recipients 21 years of age and older.

Who Is Eligible for Health Check and EPSDT?

Medicaid-eligible children through the age of 20 are eligible for Health Check and EPSDT services.

To find out if your child is eligible for Medicaid benefits, contact your local Department of Social Services (DSS). You will find them in the phone book under government agencies. You may go to the DSS to apply or ask them to send you an application in the mail. Applications are also available at the local health department. You may complete the application yourself and return it in person or mail it to the DSS.

More Information about Medicaid Eligibility

Why are Health Check and EPSDT Important?

Health Check and EPSDT are important because they:

• provide early and regular medical and dental screenings for all Medicaid eligible-children
• identify treatments that are medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination.

What Treament Services are Covered?

Services must be ordered by the child's physician or another licensed clinician. Prior approval from the Division of Medical Assistance may be required to verify medical necessity for some services.

The services must meet all of the conditions stated below:

1. The service must be medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination
2. The service must be listed in section 1905(a) of the Social Security Act.
3. The service cannot be experimental/investigational, unsafe or considered ineffective.

Requests for Non-Covered Services

If your child's physician or another licensed clinician determines that your child needs a treatment service that is not normally covered by Medicaid, they must request the service by writing to:

Assistant Director for Clinical Poalicy and Programs
Division of Medical Assistance
2501 Mail Services Center
Raleigh, NC 27699-2501
Fax 919-715-7679

What are your Rights?

If a request for service is denied or the amount of service is reduced or the service is terminated, you will be notified in writing. The letter will include information on why the request was denied and instructions on how to appeal the decision.

For More Information

You can ask about Health Check, EPSDT services, and how to obtain medically necessary services not covered by N.C. Medicaid by contacting your child's doctor, a Health Check Coordinator or the contact number listed in your Health Check letters, the local mental health program or any health care provider who accepts Medicaid.

Other Health Check and EPSDT resources are stated below:

• A Consumer's Guide to North Carolina Medicaid Health Insurance Program for Families and Children
• Health Check and Health Choice: Basic Information for Consumers from the N.C. Healthy Start Foundation
• Health Check Coordinator Contact List
• EPSDT Policy Instructions Update, August 2007

Updated August 17, 2007