EPSDT Services: Claims for Visits

(A) Initial EPSDT Visit. A provider may bill for only one initial EPSDT visit per member. (B) Periodic Visits. For each member, a provider may bill for only one periodic visit per age level listed in the Medical Schedule. (C) Interperiodic Visits. There is no limit on the number of medically necessary interperiodic visits that may be billed. Only interperiodic visits, at which the full range of EPSDT screening services are delivered, are payable as EPSDT periodic visits, subject to the limitations in 130 CMR 450.145(B). Any other interperiodic visit is payable according to the visit service codes and descriptions in Subchapter 6 of the screening provider's MassHealth provider manual. (D) Newborn Visits. (Physician, physician assistant, certified nurse practitioner, certified nurse midwife, and community health center providers only) (1) To be paid for an EPSDT periodic visit of a newborn, the provider must have visited the newborn at least twice before the newborn leaves the hospital. (a) The first visit, for an initial history and physical examination, is payable as newborn care and not as an EPSDT periodic visit. (b) The second visit, for a discharge history, physical examination, and all other screens required for the newborn, is payable as an EPSDT periodic visit. (2) Additional hospital visits for ill newborns are payable according to the service codes and descriptions for hospital visits. (3) The newborn EPSDT periodic visit may occur at the provider's office if the infant's length of stay in the hospital is not long enough for the provider to visit the infant twice before the infant is discharged from the hospital. (E) Reporting Requirement. To claim payment for an EPSDT initial, periodic, or interperiodic visit, a provider must submit a completed claim according to the MassHealth agency’s billing and claims submission requirements.