​Utilizing the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program for Children and Youth​

May 06, 2024

The goal of the EPSDT program is to ensure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. 

MaineCare’s EPSDT program allows MaineCare members under the age of 21 to receive services that are not typically covered due to limits on the type, frequency, or duration of the service. These services can include preventive, dental, developmental, behavioral and/or mental health, and specialty services.   

For example, MaineCare’s dental benefit covers one crown per tooth per five years, but if the service meets the EPSDT criteria and is approved as an EPSDT service, children, and youth under 21 can exceed this limit.  

EPSDT Criteria:  

In accordance with MaineCare Benefits Manual (MBM), Chapter II, Section 94, for services to be approved under the EPSDT program, they must:   

• be documented scientifically with valid clinical evidence of effectiveness;  not be considered investigational or experimental;   

• be the most cost-effective service that would provide the member with the same medically necessary outcome and intended purpose;  

• be prior authorized by the Authorization Unit of MaineCare Services. Requests for prior authorization of Durable Medical Equipment will be reviewed by an authorized agent of the Department;   

• be medically necessary as defined in Chapter I, Section 1.02 (D) , “General Administrative Policies and Procedures”, of the MBM;      

• not be custodial, academic, educational, vocational, recreational or social in nature as described in Chapter I, Section 1.02 (D);  

• not be respite care, which is defined as services given to individuals unable to care for themselves that are provided on a short-term basis because of the absence or need for relief of those persons normally providing the care. 

Requesting an EPSDT Prior Authorization (PA):  

Providers are required to submit a PA request for services to be considered under the EPSDT program. For services that are NOT behavioral/mental health services, this can be done through the MaineCare HealthPAS Online Portal. If you have questions about submitting a PA request through the online portal, you can contact your Provider Relations Specialist.  

If you are a MaineCare enrolled provider and do not have access to the MaineCare HealthPAS Online Portal, please visit the HealthPAS Registration page to gain access through your Trading Partner Account (TPA). For questions regarding the registration process, please contact Gainwell Technologies at 1-866-690-5585 or by email at MaineCareProvider@gainwelltechnologies.com. 

When completing PA requests, providers should include as much detail as possible to explain the plan of care, including:  

• The conditions that the plan addresses.   

• The services needed to address the conditions and why those services meet medical needs.   

• The providers who will provide the needed services.     

Additionally, health care providers need to provide documentation of medical necessity, including:   

• Supporting medical records.   

• Other services that have been tried, if any.   

• Explanation why the services are of a type, frequency or duration not otherwise covered by MaineCare.   

• Explanation why services covered in the MBM are insufficient or inappropriate.   

• Supporting medical literature which demonstrates that the proposed services will be effective.    

Providers MUST include the EPSDT modifier, which is “EP”, for the corresponding CPT/HCPCS code(s) when completing the PA request. Providers also need to check the corresponding box on the online form to identify the PA type as EPSDT related.  

For services that ARE behavioral/mental health services, authorizations are processed through Acentra Health. Providers should submit supplemental information regarding medical necessity to Acentra with the referral or request, through the Atrezzo portal. For questions specific to the Acentra authorization process or the Atrezzo Portal, contact Acentra Provider Relations at 866-521-0027, Option 3. Or via email.  

Billing for Services Approved Under EPSDT:  

If a PA is granted for an EPSDT service, please follow the billing instructions below for specific claims forms. 

CMS 1500 Billing Instructions  

• Box 24H, EPSDT Family Plan: Enter a “Y” if a service is approved under EPSDT.   

• HCPCS/RATES/HIPPS Code: Use the appropriate “EP” modifier, along with the procedure code approved under EPSDT.    

UB 04 Billing Instructions   

• FL 18 – 28, Condition Codes: Enter code “A1” into one of the condition code boxes.  

• FL 44, HCPCS/RATES/HIPPS Codes: Use the appropriate “EP” modifier, along with the procedure code approved under EPSDT.  

Dental Services Billing Instructions   

• Box 1, Type of Transaction: Enter an “X” in the box next to the EPSDT option for services approved under EPSDT.   

• Box 24, Procedure Date: Enter procedure date if “EPSDT/Title XIX” is marked in Box 1.   

For more information regarding EPSDT service billing, please see MaineCare's Billing Instructions Guides or contact your MaineCare Provider Relations Specialist. 

Standards of Care: States, under EPSDT, are required by Centers for Medicare & Medicaid Services (CMS) to adopt national standards of care. MaineCare has adopted the most recent version of the Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents of the American Academy of Pediatrics (AAP) as the standard of care expected at all health assessment visits for MaineCare members under the age of 21. MaineCare providers should utilize the American Academy of Pediatrics (AAP) Bright Futures Guidelines and MaineCare’s Recommendations for Preventive Pediatric Oral Health Care.  

For further information, please contact Becky Parsons, EPSDT Program Coordinator, at DHHS.EPSDT@maine.gov. You can also visit MaineCare’s Children’s Services webpage for various resources.