Find information about the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit and learn about coverage, tools, codes, modifier, the recent HCA addition to the modifier requirement, and more.
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What developmental and behavioral health screenings are covered?
What developmental and behavioral health screenings are covered?
Apple Health (Medicaid) covers all medically necessary screenings provided to children and youth in alignment with Early and Periodic Screening Diagnostic, and Treatment (EPSDT). Typical developmental and behavioral health screenings included as a part of the well-child checkup include:
- Child development, including screening for autism
- Depression, anxiety, and substance use
- Caregiver depression screening during the first year after pregnancy
All covered screenings align with National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) maximum units of service.
What screening tools should I use?
What screening tools should I use?
Screenings use standardized tools which may include client and caregiver interview and observation. Providers may reference American Academy of Pediatrics Bright Futures Toolkit for Commonly Used Screening Instruments for examples of available standardized tools.
What codes should I use?
What codes should I use?
HCA publishes Apple Health billing guides to provide information on billing practice for all Apple Health providers. The EPSDT Well-Child program billing guide includes information on how to bill for screening.
Find billing guides on the Provider Billing Guides & Fee Schedules webpage.
What modifier do I use for screenings?
What modifier do I use for screenings?
HCA is allowing providers to submit claims for reimbursement without a modifier until July 1, 2025 to allow time for workflow changes and system updates.
Effective July 1, 2025, providers must submit the appropriate CPT® code accompanied by one of the following modifiers to indicate whether a need was identified to receive reimbursement.
| Modifier | Description |
| U1 | No need is identified (negative screen). Indicates screening score within a normal range |
| U2 | Need is identified (positive screen). Indicates risk concern, impairment, or identification of developmental and/or behavioral disorder. |
Why did the Health Care Authority add the modifier requirement?
Why did the Health Care Authority add the modifier requirement?
Inclusion of the modifier allows for access of screening outcomes to coordinate care, track referrals and service engagement, and inform future policy based on prevalence of identified needs. Examples of ways this data may inform future policies include but are not limited to:
- Increased reimbursement for positive screenings to account for additional services and supports
- Gap analysis for identified need versus service availability for programs such as Early Supports for Infants and Toddlers and behavioral health services for children and youth
- Value-based payment modeling
What is the reimbursement for using the modifier?
What is the reimbursement for using the modifier?
To receive reimbursement, providers are required to include a modifier indicating the screening outcome. Reimbursement is the same regardless of the screening outcome. Visit the Provider Billing Guides & Fee Schedules webpage for current rates.
What are the requirements for follow-up and referrals when there is a concern identified?
What are the requirements for follow-up and referrals when there is a concern identified?
In alignment with federal requirements, the HCA requires providers to ensure the child and family receive all medically necessary services for issues identified during a well-child checkup. This may include requesting a noncovered service, directly treating an identified issue, or referring to other providers.
Who do I contact if I have a billing question or issue?
Who do I contact if I have a billing question or issue?
See the Apple Health Clinical Policy & Billing Contact Information Apple Health clinical policy and billing contact information to connect with HCA and managed care organizations (MCO).
If you have any other questions or concerns, please email [email protected]
