What is HealthCheck?
A federal law called Early Periodic Screening Diagnosis and Treatment (EPSDT)
requires state Medicaid programs to provide screening, diagnosis, and treatment services for members under 21 years of age, including dependent children and childless adults. In Wisconsin, EPSDT is called “HealthCheck.” The goal of HealthCheck is to obtain the best results for children by preventing, diagnosing, and treating health problems as early as possible.
Although Congress created EPSDT over 50 years ago, it is not well known. HealthCheck is underutilized for a variety of reasons
, including lack of provider and community knowledge and prior authorization process/denials.
How Can HealthCheck Help Wisconsin Children?
When is a Requested Service “Medically Necessary” Under HealthCheck?
- “Well Child” Checks and Interperiodic Screens are available without prior authorization and include comprehensive health and developmental history (including behavioral health), comprehensive physical exam, vision and hearing screens, oral assessment and referral to a dentist, laboratory tests, and vaccines. HealthCheck follows a schedule for periodic examinations outlined by the American Academy of Pediatrics.
- Outreach and Case Management Services are available without prior authorization and include scheduling and coordinating transportation to appointments and arranging referrals and follow up appointments.
- HealthCheck “Other Services” generally require prior authorization and include medically necessary services not typically covered by Wisconsin Medicaid. This can include services such as durable medical equipment, therapies (such as speech, hearing, occupational, and physical), in home and day treatment mental health services, home health services, hearing aids, orthodontia, rehabilitation services, medications (both prescription and over-the-counter), some dental services, and more. Prior authorization requests should include a clear explanation of how the requested service/product is medically necessary.
The definition of “medically necessity” is broader under HealthCheck. The requested service is “medically necessary” under HealthCheck if it is likely to correct or ameliorate the child’s condition, including maintaining current status or preventing regression. The decision is made on a case-by-case basis on the needs of the child. The requested service must also meet the medical necessity standards cited in Wis. Admin. Code § DHS 101.03(96m)
What if a Prior Authorization is Denied?
If a prior authorization is denied, the child’s family or an authorized representative may appeal
. Families may wish to ask for representation or assistance either through their healthcare system or a legal services agency such as Legal Action of Wisconsin
or Wisconsin Judicare
Where Can I Find More Information About HealthCheck?