Ala. Admin. Code r. 560-X-11-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-11-.09 - EPSDT Referral For Services

(1) All participating EPSDT providers will complete the EPSDT Referral for Services form for each individual provider to whom a person is being referred to for further diagnosis and/or treatment.

(2) When a screening provider refers a person to a Medicaid participating provider for diagnosis and/or treatment, all treatment services will be considered for reimbursement, above current limitations. However, the services rendered must be medically necessary to treat or ameliorate a condition or diagnosis identified in a screen.

(3) The referring provider must document within the patient's medical history or physical examination portion of the medical record the condition(s) identified during an EPSDT Screening examination which requires a referral. Notation of the condition on the EPSDT referral form alone will not be considered sufficient documentation. Medicaid has the right to recoup payment for the screening service from the referring provider, when a referral is made for a condition not documented in the medical history or physical examination portion of the medical record.

(4) Alabama Medicaid Agency Administrative Code, Chapter One, General, contains information about extended benefits as a result of an EPSDT screening and referral.

Author: Laurie McEnery

Ala. Admin. Code r. 560-X-11-.09

Rule effective October 1, 1982. Emergency rule effective December 1, 1986. Amended: Effective March 12, 1987. Emergency rule effective October 1, 1990. Amended: Effective February 13, 1991. Amended: Filed June 6, 1995; effective July 11, 1995.

Statutory Authority: Title XIX, Social Security Act; State Plan; 42 C.F.R. §441.61; OBRA '89 §6403.