TennCare Standard Operating Procedures
STATE OF TENNESSEE
BUREAU OF TENNCARE
DEPARTMENT OF FINANCE AND ADMINISTRATION
729 CHURCH STREET
NASHVILLE, TENNESSEE 37247-6501
MEMORANDUM
DATE: February 23, 2001
TO: TennCare MCOs & BHOs
TSOP: 036 Addendum 4
FROM: Mark E. Reynolds
Deputy Commissioner
SUBJECT: Interperiodic Screenings
The Social Security Act (the Act), as amended by OBRA 89, requires that under the EPSDT benefit, state Medicaid programs must provide for screenings, including vision, hearing, and dental screenings, at intervals which meet the reasonable standards of medical and dental practice. The Bureau of TennCare has adopted the periodicity schedule recommended by the American Academy of Pediatrics (AAP) for Preventive Pediatric Health Care. Per the TennCare/MCO/BHO contracts, MCOs and BHOs are required to furnish EPSDT screenings, diagnostic, and treatment services to all TennCare-eligible children under the age of 21 at periodic intervals of the child's life.
In addition, section 1905(r) of the Act requires that "interperiodic" screens be provided when necessary and this strengthens the preventive nature of the EPSDT program by providing screening, diagnostic, and treatment services between otherwise scheduled examinations. An "interperiodic" screen is a partial screening conducted outside of the regularly scheduled periodic screening. The interperiodic screen gives attention to the suspected problem to determine if additional diagnostic and treatment services are needed. There would be no need to complete all of the required components of a regular EPSDT periodic screen if written verification exists to show that the most recent age-appropriate screening services, due under the AAP periodicity schedule, has already been provided to the member.
The determination of whether an interperiodic screen is necessary may be made by a health, developmental, or educational professional who comes in contact with the child outside of the formal health care system (e.g., Early Intervention Programs, Head Start, and nutritional programs such as the Special Supplemental Food Program for Women, Infants and Children). Likewise, parents, guardians, or family members can make determinations of whether an interperiodic screen is necessary when it is suspected that a child is having problems. For example, a child who is screened at age 10 according to the periodicity schedule for EPSDT screenings would not be due for another screening until age 11. However, if six months later the child's schoolteacher suspects that the child is having hearing trouble the schoolteacher should immediately refer the child to a primary care provider (PCP) for an interperiodic screen to determine if there is a problem that needs further attention. There is no need to wait until the next regularly scheduled periodic screening.
Contractors may not impose prior authorization requirements on periodic screens or interperiodic screens conducted by the primary care provider and must provide all medically necessary, TennCare-covered services. While there is no requirement that EPSDT periodic or interperiodic screenings be medically necessary, additional testing and treatment services must meet the medically necessary criteria.
Follow-up is just as important as the screening. Providers who perform EPSDT periodic and interperiodic screens may identify potential health, developmental, or behavioral problems and they are responsible for making referrals to other MCO and BHO providers to do further testing or to provide treatment, as appropriate.
ESPDT periodic and interperiodic screens are not subject to cost sharing responsibilities, however, cost-sharing responsibilities may apply to diagnostic and treatment services if the member has cost-sharing responsibilities. Contractors should assist with the scheduling of periodic and interperiodic screens when requested and provide transportation to said screens as appropriate.
TennCare Authority:
42 U.S.C §§ 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)
42 C.F.R. § 440.230
42 C.F.R. § 441, Subpart B
HCFA's State Medicaid Manual
TennCare Rules and Regulations 1200-13-12-.04(1)(w)
TennCare/MCO Contract Section 2-3.a.1.; Section 4-8.
TennCare/BHO Contract Section 2.6.1.; Section 5.3.3.1.
