Child Health Check-Up (formerly EPSDT) - Herman & Associates ...

Child Health Check-Up Coverage and Limitations HandbookService Requirements, continuedMedicallyNecessaryChapter 59G-1.010 (166), Florida Administrative Code defines medicallynecessary as follows:(166) “Medically necessary” or “medical necessity” means that the medical orallied care, goods, or services furnished or ordered must:(a) Meet the following conditions:1. Be necessary to protect life, to prevent significant illness or significantdisability, or to alleviate severe pain;2. Be individualized, specific, and consistent with symptoms or confirmeddiagnosis of the illness or injury under treatment, and not in excess of thepatient’s needs;3. Be consistent with generally accepted professional medical standards asdetermined by the Medicaid program, and not experimental or investigational;4. Be reflective of the level of service that can be safely furnished, and forwhich no equally effective and more conservative or less costly treatment isavailable statewide; and5. Be furnished in a manner not primarily intended for the convenience of therecipient, the recipient's caretaker, or the provider.(b) “Medically necessary” or “medical necessity” for inpatient hospital servicesrequires that those services furnished in a hospital on an inpatient basis couldnot, consistent with the provisions of appropriate medical care, be effectivelyfurnished more economically on an outpatient basis or in an inpatient facility of adifferent type.(c) The fact that a provider has prescribed, recommended, or approved medicalor allied care, goods, or services does not, in itself, make such care, goods orservices medically necessary or a medical necessity or a covered service.Child Health Check-Up Periodicity ScheduleIntroductionTo receive Medicaid reimbursement for Child Health Check-Ups, providers mustfollow the Child Health Check-Up periodicity schedule. The schedule is basedon the American Academy of Pediatrics, “Recommendations for PreventivePediatric Health Care” and Florida Medicaid’s recommendation to include the 7and 9 year old recipients.2-4 October 2003