EPSDT Policy Update

CSC is assuming responsibility from the North Carolina Division of Medical Assistance (DMA) for processing EPSDT prior approvals. Beginning with dates of service April 1, 2014, CSC will process all prior approval requests for services coverable for children under 21 years of age under the scope of Medicaid’s EPSDT * benefit. EPSDT prior approvals with dates of service prior to this date are still being processed by DMA.

Note: Behavioral Health and Waiver services are not impacted by this change. Local Management Entities - Managed Care Organizations (LME-MCO) and Value Options continue to review and authorize prior approvals for these service areas.

The EPSDT Policy Instructions Update, revised January 11, 2010, and found at http://www.ncdhhs.gov/dma/epsdt/epsdtpolicyinstructions.pdf remains the same, except for the following:
1. CSC will process EPSDT prior approval requests for services needed that exceed clinical coverage policy limits in the following programs: Dental, Orthodontic, Durable Medical Equipment (DME) including Orthotics and Prosthetics, Medical, Surgical, Visual Aid, Optical, Hearing Aid, and Pharmacy. Providers must use the NCTracks Provider Portal to request services that exceed clinical policy limits.
2. CSC will process all EPSDT prior approval requests for Non-Covered Services for recipients under 21 years of age. Providers must use the “Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old” found at
This Non-Covered Services form must be submitted / uploaded along with supporting documentation via NCTracks. Do not submit the form by itself. For example, if the non-covered service needed is a DME service, follow the normal process for requesting a DME Prior Approval and include the completed Non-Covered Services Form along with supporting documentation. 
Please note that the previous DMA version of this form is no longer available.
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* Federal Medicaid law at 42 U.S.C.§ 1396d(r) [1905(r) of the Social Security Act] requires state Medicaid programs to provide Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for recipients under 21 years of age. Within the scope of EPSDT benefits under the federal Medicaid law, states are required to cover any service that is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,” whether or not the service is covered under the North Carolina State Medicaid Plan. The services covered under EPSDT are limited to those within the scope of the category of services listed in the federal law at 42 U.S.C. § 1396d (a) [1905(a) of the Social Security Act].