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Introduction:
Diagnosis, Treatment, and Referral Requirements
 Providing
effective health supervision (as presented in the HealthCheck
Periodicity) helps to ensure that health problems are identified,
diagnosed, and treated early before they become more serious
and the treatment more costly.
Federal EPSDT
legislation requires coverage of any services “that are necessary
to treat or ameliorate a defect, physical and mental illness or
condition identified by a screen.” Such services are allowed
under the federal law regardless of whether they are included in
the State Plan.
Providers are
required to document any well-child screens that result in the
need for treatment and/or referral. All HealthCheck treatment
should be reported to the MCO or MAA via claims for fee-for-service
members.
Diagnosis
Providers are
required to either perform the service indicated or make a prompt
and appropriate referral for diagnosis and/or treatment when a physical
or behavioral health problem is detected in a health, vision, or
hearing screening assessment. Any necessary referrals should be
made at the time of preventive health supervision, if possible.
Providers and
MCOs must make all reasonable efforts to follow up on referrals
for treatment, including referrals made outside the DC Medicaid
Managed Care Program, such as mental health referrals. Fee-for-service
providers will give the parents or guardian freedom of choice of
providers when making a referral. MCOs may limit referrals for covered
services to their provider network and should give the parents or
guardian freedom of choice of providers when making a referral for
non-covered services. All treatment, including referral treatment,
should begin within 60 days of the screening.
Treatment
Treatment services
include, but are not limited to, the following:
- Physician
services
- Outpatient
hospital services
- Inpatient
hospital services
- Home
health services
- Eyeglasses
- Family
planning services
- Hospice
care
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- Nurse
Midwife services
- Physical,
occupational and speech therapies
- Private-duty
nursing services
- Prostheses
and other durable medical equipment
- Skilled
nursing facility services
- Extended
services for pregnant women
- Rehabilitative
services
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Referral
Referrals
for diagnosis and initial treatment should not be limited solely
to services covered by Medicaid or Medicaid-enrolled providers.
All medically
necessary services must be provided, whether or not they are
covered
by DC's State Medicaid Plan.
Referrals
must be made to the appropriate provider for diagnosis and treatment
for each health finding.
This
concludes the Introduction to
Health Supervision module.
The next page contains Review Questions for the information presented in this module.
Move on to the next module, Health
and Developmental History, after completing the
review questions.
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