Section 51340 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services and EPSDT Supplemental Services(a) EPSDT screening services as defined in Section 51184(a)(1) are a program benefit when provided through the Child Health and Disability Prevention program in accordance with Title 17, California Code of Regulations, Sections 6800 et seq. EPSDT screening services as defined in Sections 51184(a)(2) and (a)(3) are covered when provided by a certified Medi-Cal provider meeting the requirements of this chapter, if such services are otherwise reimbursable under the program.(b) EPSDT diagnosis and treatment services as defined in Section 51184(b) are covered subject to the provisions of this chapter.(c) Unless otherwise specified in this Chapter, EPSDT supplemental services are covered subject to prior authorization if the requirements of subsections (e) or (f), as appropriate, are met. The Department shall review requests for services resulting from EPSDT screening services for compliance with this section whether the screen was performed by a Medi-Cal provider or a non-Medi-Cal provider.(d) Requests for prior authorization for EPSDT supplemental services pursuant to subsection (c) shall state explicitly that the request is for EPSDT supplemental services, and shall be accompanied by the following information: (1) The principal diagnosis and significant associated diagnoses.(3) Date of onset of the illness or condition, and etiology if known.(4) Clinical significance or functional impairment caused by the illness or condition.(5) Specific types of services to be rendered by each discipline with physician's prescription where applicable.(6) The therapeutic goals to be achieved by each discipline, and anticipated time for achievement of goals.(7) The extent to which health care services have been previously provided to address the illness or condition, and results demonstrated by prior care.(8) Any other documentation available which may assist the Department in making the determinations required by this section.(e) EPSDT supplemental services must meet one of the following standards, as determined by the Department: (1) The standards and requirements set forth in Sections 51003 and 51303, and any specific requirements applicable to a specific service that are based on the standards and requirements of those sections other than the service-specific requirements set forth in Section 51340.1.(2) The service-specific requirements applicable to EPSDT Supplemental Services set forth in Section 51340.1.(3) When the standards set forth in paragraph (e)(1) or (e)(2) are not applicable to the services being requested, all of the following criteria, where applicable: (A) The services are necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services as defined in subsection (a) of this section.(B) The supplies, items, or equipment to be provided are medical in nature.(C) The services are not requested solely for the convenience of the beneficiary, family, physician or another provider of services.(D) The services are not unsafe for the individual EPSDT-eligible beneficiary, and are not experimental.(E) The services are neither primarily cosmetic in nature nor primarily for the purpose of improving the beneficiary's appearance. The correction of severe or disabling disfigurement shall not be considered to be primarily cosmetic nor primarily for the purpose of improving the beneficiary's appearance.(F) Where alternative medically accepted modes of treatment are available, the services are the most cost-effective.(G) The services to be provided:1. Are generally accepted by the professional medical and dental community as effective and proven treatments for the conditions for which they are proposed to be used. Such acceptance shall be demonstrated by scientific evidence, consisting of well designed and well conducted investigations published in peer-review journals, and, when available, opinions and evaluations published by national medical and dental organizations, consensus panels, and other technology evaluation bodies. Such evidence shall demonstrate that the services can correct or ameliorate the conditions for which they are prescribed.2. Are within the authorized scope of practice of the provider, and are an appropriate mode of treatment for the health condition of the beneficiary.(H) The predicted beneficial outcome of the services outweighs potential harmful effects.(I) Available scientific evidence, as described in paragraph (e)(3)(G)1., demonstrates that the services improve the overall health outcomes as much as, or more than, established alternatives.(f)(1) Notwithstanding subsection (e), EPSDT case management services as specified in paragraph (j)(3) may be covered for the EPSDT-eligible beneficiary when accompanied by the information described in subsection (d) if the Department determines that both of the following criteria are met: (A) The service to which access is to be gained through case management is medically necessary for the EPSDT-eligible beneficiary. For purposes of this subsection, medical necessity is established if the service meets the criteria set forth in subsection (e)(1), (e)(2), or (e)(3).(B) The EPSDT-eligible beneficiary has a medical or mental health condition or diagnosis.(2) Requests for EPSDT case management services shall not be approved if the Department determines that EPSDT case management services appropriate to the EPSDT-eligible beneficiary's needs can reasonably be obtained through the use of family, agency, or institutional assistance that is typically used by the general public in assuring that children obtain necessary medical, social, educational, or other services. In making the determination described in this paragraph, the Department may take into account the following factors: (A) Whether or not the beneficiary has a complicated medical condition, including a history of multiple or complex medical or mental health diagnoses, frequent recent hospitalizations, use of emergency rooms, or other indicators of medical or mental health conditions resulting in significant impairment.(B) Whether or not the beneficiary has a history of one or more environmental risk factors, including: 1. parent, guardian, or primary care-giver mental retardation or mental illness, physical or sensory disability, substance abuse, under age 18 years, prolonged absence, or2. other environmental stressors, which may result in neglect, abuse, lack of stable housing, or otherwise compromise the parent's, guardian's, or primary caregiver's ability to assist the beneficiary in gaining access to the necessary medical, social, educational, and other services.(g) If reimbursement is being sought on a "by report" basis, a description of the service, the proposed unit of service, and the requested dollar amount shall be included with the request for authorization. A "by report" service or item is any service for which a maximum allowance has not been established because the item is rarely billed to the Medi-Cal program or because the service is unusual, variable or new.(h) EPSDT supplemental services requested as a result of EPSDT screening services are exempt from the benefit limitations in Section 51304, and may be covered subject to prior authorization as defined in Section 51003 if the requirements of subsection (e) of this section are met.(i) Regardless of the source of the referral for the service, requests for EPSDT diagnostic and treatment services and EPSDT supplemental services pursuant to the requirements of this chapter shall be reviewed pursuant to this section.(j)(1) Requests for EPSDT case management services shall not be authorized where the Department has determined that appropriate case management services may be obtained through a targeted case management (TCM) provider under contract with a participating local governmental agency that has elected to provide case management services pursuant to Section 14132.44 of the Welfare and Institutions Code, or where TCM services are available pursuant to Section 14132.48 of the Welfare and Institutions Code.(2) Where the Department determines that EPSDT case management services are not provided or available pursuant to paragraph (j)(1), requests for EPSDT case management services may be referred to the unit within the Department designated by the Director.(3) Where the Department determines that EPSDT case management services are not provided or available pursuant to paragraph (j)(1) or (j)(2), the Department may authorize EPSDT case management services through an EPSDT case manager described in Section 51184(h)(4).(k) For members of Medi-Cal managed care plans, the Medi-Cal managed care plan shall determine whether EPSDT case management services are medically necessary based on subsection (f). If the plan determines EPSDT case management services are medically necessary, the plan shall refer the members to an appropriate EPSDT case manager described in paragraph (h)(1) or (h)(2) of Section 51184. Services shall first be sought pursuant to paragraph (j)(1). If services are not available pursuant to paragraph (j)(1), the plan shall provide, or arrange and pay for, the EPSDT case management services. For purposes of this subsection, Medi-Cal managed care plan means any entity that has entered into a contract with the Department to provide, or arrange for, comprehensive health care to enrolled Medi-Cal beneficiaries pursuant to Chapter 8 or Articles 2.7, 2.8, 2.9 and 2.91 of Chapter 7 of Part 3, Division 9, of the Welfare and Institutions Code.(l) The Department shall not approve an EPSDT supplemental service pursuant to this section if the Department determines that the service to be provided is accessible and available in an appropriate and timely manner as an EPSDT diagnostic and treatment service.(m) The Department shall not approve a request for EPSDT diagnostic and treatment services or EPSDT supplemental services in home and community-based settings if the Department determines that the total cost incurred by the Medi-Cal program for providing such services to the beneficiary is greater than the total costs incurred by the Medi-Cal program in providing medically equivalent services at the beneficiary's otherwise appropriate institutional level of care, where medically equivalent services at the appropriate level are available in a timely manner.Cal. Code Regs. Tit. 22, § 51340
1. New section filed 2-27-75; effective thirtieth day thereafter (Register 75, No. 9).
2. Change without regulatory effect of NOTE (Register 86, No. 49).
3. Amendment of section heading, text, and NOTE filed 4-4-94 as an emergency; operative 4-4-94 (Register 94, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-2-94 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section heading, text and NOTE refiled 8-1-94 as an emergency; operative 8-1-94 (Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-29-94 or emergency language will be repealed by operation of law on the following day.
5. Editorial correction of printing errors in subsections (d)(1), (e) and (i) (Register 94, No. 31).
6. Amendment of section heading, text and NOTE refiled 10-24-94 as an emergency; operative 10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-21-95 or emergency language will be repealed by operation of law on the following day.
7. Amendment of section heading, text and NOTE refiled 2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-95 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
9. Amendment of subsection (c) and amendment of NOTE filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
10. Amendment of subsection (c) and amendment of NOTE refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2). Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14059 and 14132, Welfare and Institutions Code; Sections 306- 309, Health and Safety Code; and 42 U.S.C. 1396d(r).
1. New section filed 2-27-75; effective thirtieth day thereafter (Register 75, No. 9).
2. Change without regulatory effect of NOTE (Register 86, No. 49).
3. Amendment of section heading, text, and Note filed 4-4-94 as an emergency; operative 4-4-94 (Register 94, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-2-94 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section heading, text and Note refiled 8-1-94 as an emergency; operative 8-1-94 (Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-29-94 or emergency language will be repealed by operation of law on the following day.
5. Editorial correction of printing errors in subsections (d)(1), (e) and (i) (Register 94, No. 31).
6. Amendment of section heading, text and Note refiled 10-24-94 as an emergency; operative 10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-21-95 or emergency language will be repealed by operation of law on the following day.
7. Amendment of section heading, text and Note refiled 2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-95 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
9. Amendment of subsection (c) and amendment of Note filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
10. Amendment of subsection (c) and amendment of Note refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).