EPSDT/CHDP Frequently Asked Questions

Child Health and Disability Prevention (CHDP) providers billing for services provided to children and youth enrolled in the Medi-Cal fee-for-service health care delivery system must submit claims directly to the California Medicaid Management Information System (MMIS) Fiscal Intermediary in accordance with HIPAA national standards. Depending on the type of provider, claims must be submitted using CPT® national codes on the CMS-1500, UB-04 claim form, or their respective electronic equivalent.

Codes

  1. What national codes should providers submit?

    CPT codes determined to be most appropriate for EPSDT/CHDP (Early and Periodic Screening, Diagnostic and Treatment/Child Health and Disability Prevention) services. Providers should bill CPT codes that correspond to the services rendered.

Billing Limitations

  1. Can claims submitted one year from the date of service be reimbursed at the full rate?

    No. Claims processed in the Medi-Cal claims system are subject to the six-month billing limitation. After six months, reimbursement will be reduced unless a valid late submission reason is entered on the claim, with supporting documentation as appropriate.

Claim Form

  1. Which claim form is used to bill EPSDT/CHDP services?

    For paper submissions, providers will bill using the CMS-1500 or Outpatient UB-04 claim form. For electronic submissions, providers use the ANSI X12N 837 professional (837P) or 837 institutional (837I) electronic claim format.

  2. Can CHDP providers use the Additional Claim Information field (Box 19) on the CMS-1500 claim form or the Remarks field (Box 80) on the UB-04 claim form?

    Yes. Box 19 on the CMS-1500 and Box 80 on the UB-04 will be available to enter documentation, delay reason remarks and additional information as needed.

  3. Is the county code required on the CMS-1500 or UB-04?

    No. The county code is not required on the national claim forms.

  4. Should the date of the next periodic health exam be entered on the CMS-1500 or UB-04? If so, where is it entered on the claim?

    National claim forms do not have fields to capture the date for the next required periodic exam. Well-child health assessments and immunizations should be rendered in accordance with the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule. See both the CHDP Bright Futures Schedule for Health Assessments by Age Group and CHDP/EPSDT Periodicity Schedule for Dental Referral by Age PDFs for guidelines.

Electronic Claim Completion

  1. How is an attachment added to an electronic claim?

    For each electronically submitted claim requiring an attachment, a single and unique Attachment Control Form (ACF) must be submitted via mail or fax. Providers will be required to use the 11-digit Attachment Control Number (ACN) from the ACF to populate the Paperwork (PWK) segment of the 837 HIPAA transaction.

    Both the electronically submitted 837P and 837I ANSI ASC X12N v.5010A1 claim and the paper attachment must contain the ACN to allow the parts of the claim to be synced for processing.

  2. I currently have a submitter who processes my electronic CHDP claims. What would they have to do to submit my CHDP electronic claims?

    The submitter must be approved to submit the CMS-1500 or UB-04 claims electronically. Instructions are available on the Medi-Cal website or by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Billing

  1. Physicians bill lab codes for services performed during the CHDP exam. Should physicians continue billing for those services the same way?

    Medi-Cal physicians need to bill for these services in accordance with their Medi-Cal enrollment status. If the physician is not authorized to bill for the specific lab codes under their Medi-Cal enrollment, the claim will be denied.

  2. How do CHDP providers bill a partial screening service?

    Providers use the appropriate procedure codes with specified modifiers according to Medi-Cal billing instructions when billing for partial screening services. Refer to the Preventive Services section in the Medi-Cal provider manual.

Rates

  1. Is rate information available online?

    The Medi-Cal rate table may be accessed from the Medi-Cal website: Under the References tab providers should click “Medi-Cal Rates.”

Miscellaneous Questions

  1. Why were CHDP local codes changed to national codes?

    The Federal Health Insurance Portability and Accountability Act (HIPAA) requires electronic health care transactions, and their hard copy counterparts, to conform to national standards for electronic health care transactions and use of national standard code sets as specified in federal regulations adopted by the Department of Health and Human Services.

  2. Are ICD-10-CM diagnosis codes required on my claim?

    Yes, if the policy instructions in the Medi-Cal provider manual say an ICD-10-CM diagnosis is required for the service being billed.

  3. Where can I find information regarding EPSDT/CHDP in the Provider Manual?

    Information regarding EPSDT/CHDP can be accessed through the following provider manual sections:

    EPSDT/CHDP

    EPSDT/CHDP: Gateway

    EPSDT/CHDP: School-Based Services

  4. Where can I find help for submitting a claim for EPSDT/CHDP services?

    Providers can receive training on submitting CMS-1500 or UB-04 claim forms through the computer-based training (CBT) course that is available on the Medi-Cal Learning Portal (MLP). Providers may also contact the Telephone Service Center (TSC) at 1-800-541-5555.

  5. Will providers currently billing for CHDP services be able to bill Medi-Cal for CHDP-related Early and Periodic Screening, Diagnostic and Treatment (EPSDT) health assessments and immunizations?

    CHDP-approved providers are eligible to bill Medi-Cal for CHDP-related well-child health assessments, immunizations and laboratory services rendered under the EPSDT benefit of the Medi-Cal program in accordance with the provider's Medi-Cal enrollment status; for example, Medi-Cal provider type and category of service.

  6. Will my payments appear on the Medi-Cal warrant or on a separate checkwrite?

    Claims will be adjudicated in the Medi-Cal system and reimbursements will be reflected on the provider's Medi-Cal warrant.

  7. When billing with the CMS-1500 form, will providers be required to provide the parent and county office a copy of the health assessment?

    It is not necessary to provide the county office a copy of the claim form. The health assessment provider should provide the child, parent or guardian with the results of the health screening and evaluation with an explanation of the meaning of the results.

  8. Should clinical results be entered on the CMS-1500, UB-04 or ANSI 837P/837I form?

    No. Providers document the clinical data in the recipient's records.

  9. Do providers need to enter Body Mass Index, Hemoglobin, Hematocrit and Tobacco information on the CMS-1500 form?

    Providers will be expected to perform these and other required tests and document the results in the recipients’ health records as indicated on the “CHDP Bright Futures Schedule for Health Assessments by Age Group” PDF. It is no longer required to include these metrics on the claim form.

  10. Which signatures and National Provider Identifiers (NPIs) are required when billing on the CMS-1500 form?

    The claim must be signed and dated by the provider or representative designated by the provider.

  11. Do providers need to fill out the service facility location information?

    Yes. Providers enter the provider name and address of the facility where the services were rendered, including the nine-digit ZIP code.

  12. Does the billing provider's information need to be included?

    Yes. The provider’s name and address must be entered without a comma between the city and state, including the nine-digit ZIP code without a hyphen, and the telephone number and the provider's NPI.

  13. Which signatures and NPIs are required when billing on the UB-04 form?

    Provider name, address and ZIP code are required, including the city and state with nine-digit ZIP code.

  14. Will new Medi-Cal providers interested in providing CHDP-related services have to apply to be a CHDP provider to use the CHDP Gateway or render services in accordance with the Bright Futures Periodicity Schedule?

    CHDP providers are required to be enrolled as Medi-Cal providers and approved as CHDP providers. This enables providers to submit claims for EPSDT/CHDP well-child health assessments, immunizations and ancillary services to the Medi-Cal fiscal intermediary, and to enroll youth in presumptive eligibility Medi-Cal through the CHDP Gateway. CHDP services conform to the AAP Bright Futures periodicity schedule and benefit guidelines. Claims for reimbursement for these services will be billed in accordance with Medi-Cal billing requirements, procedures and policies, and will be reimbursed at Medi-Cal rates.

Resources

Specific questions concerning billing and reimbursement may be directed to the Telephone Service Center (TSC) at 1-800-541-5555

Providers are also encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive current notifications related to CHDP or other Medi-Cal programs. CHDP providers are specifically encouraged to subscribe to the General Medicine or Clinic and Hospitals bulletin. Providers may sign up for MCSS by completing the MCSS Subscriber Form.