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Allow for only valid EPSDT services

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Claim Requirement 5.28.0

SD/MC(Short-Doyle-Medi-Cal) will deny any service for any client 21 years of age or older, or is enrolled in an aid code that is not EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) eligible.

  • Therapeutic Behavioral Services (TBS) -  service code H2019
  • Intensive Care Coordination (ICC) - service code  T1017
  • In-Home Behavioral Services (IHBS) - multiple codes
  • Therapeutic Foster Care (TFC) - service code S5145

Create an advanced billing rule to generate a report of claims that SD/MC would deny for claim requirement 5.28.0. Configure event rules to do both age and Aid code comparisons.

Prerequisites:

  • Review the Aid Code Master Chart and locate codes that have 'No' in the EPSDT column. These codes are not EPSDT eligible and require setup described in this article. The Aid Code Master Chart can be found here: https://www.dhcs.ca.gov/services/MH/...ster-Chart.pdf
  • In Dictionary Update, add the reason that a service did not meet the criteria for the EPSDT advanced billing rule to this dictionary: (Other Tabled Files: data element 1262- Reason For Failed Compliance). Example: Failed EPSDT Requirement 

Add advanced billing rule

  1. Go to: Avatar PM > System Maintenance > System Definition > Advanced Billing Rule Definition.
  2. Select Add for Add Or Edit Advanced Billing Rule.
  3. Select Yes for Active.
  4. For Advanced Billing Rule Description, enter a description that clearly identifies the rule, such as 'EPSDT'.
  5. For Rule Category select Covered Charge to filter the service codes. 
  6. Select the Service Code for EPSDT services. 
    Note: This example uses H2019 TBS Services.
  7. Select Medi-Cal for the Guarantor. 
  8. For the Effective Date, enter 07/01/2023. This is the date the new CalAIM processing requirements go into effect. 
  9. For Rule defines Conditions for, select Compliance.
    Note: This selection creates logic for all Crisis Intervention Services that exceed 8 hours will appear on the Advanced Billing Rule Compliance Report.
  10. Select Yes for Associated to Age.
  11. Select Less Than for Age Comparison.
  12. For Age, enter 22.
  13. For Reason for failed Compliance, select the reason that was added to the dictionary mentioned in the prerequisites.  
  14. For Rule Results In, select either ‘Message Only’ or ‘Liability Inhibit and Message’.
    Note: If liability is inhibited in the advanced billing rule, the liability is distributed to the next valid guarantor in the client's financial eligibility.
  15. Select File Advanced Billing Rule.
  16. Select Submit.

Add event rule for Aid code

Add an event rule for every Aid code that is not EPSDT eligible. 

  1. Still in Advanced Billing Rule Definition, select the Event Rules section.
  2. For Event Table select Treatment History.
  3. For Event Field select Aid Code.
  4. Select Specific Event for Type of Event.
  5. For Specific Value enter an Aid code with the value 'No' in the Aid Code Master Chart.
    Note: The Aid code is determined by the service code and the category the service code falls under. This value will keep with the requirement of SD/MC denying any service that is not EPSDT eligible.
  6. Select Equal To for the Relationship.
  7. Select Add Event Rule.
  8. Select Submit.
  9. Select Add Event Rule.
    Result: The advanced billing rule creates a message when an EPSDT service is billed for a client over 21 years of age or enrolled in an invalid Aid code.

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► Example

In this example the client Percy Jackson is age 19 and eligible for EPSDT services. However, they have the aid code F3 assigned to them, which is not eligible for EPSDT services.

In the event rule the Specific Value (Dictionary) value is F3 (Adult County Inmate Program).

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The Advanced Billing Failed Compliance Report shows the service.

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