As provided under federal law, Mercy Care is required to "pay and chase" claims for preventive pediatric services, including EPSDT services, even when a third party payor exists. This means that Mercy Care cannot engage in cost avoidance of claims that are submitted for preventive pediatric care services. The provision of medically necessary AHCCCS covered services is separate and apart from payment of services and coordination of benefits (COB) responsibilities. Mercy Care is prohibited from denying authorization of covered medically necessary services due to the existence of another insurer or potential third party payor.
Preventive pediatric care, including EPSDT covered services, refers to screening and diagnostic services to identify congenital, physical, mental health routine examinations performed in the absence of complaints, and screening or treatment designed to avert various infectious and communicable diseases from ever occurring in children under age 21. This includes immunizations, screening tests for congenital disorders, well child visits, preventive medicine visits, preventive dental care, screening and preventive treatment for infectious and communicable diseases, and behavioral health exams.
As stated above, Mercy Care is not permitted to cost avoid claims that are submitted for preventive pediatric services
Examples of Preventive Pediatric Services:
Physical Health
All types of health conditions — medical, dental, developmental, acute, and chronic — must be treated, including pre-existing conditions or those detected outside of a comprehensive well-child "screening" visit. Some common treatment and intervention services include: specialty referrals (initial consultation and subsequent visits related to the issue), eyeglasses, hearing aids, durable medical equipment such as wheelchairs and prosthetic devices, occupational, physical and speech therapies, prescribed medical formula foods, assistive communication devices, therapeutic behavioral services, and substance abuse treatment.
Behavioral Health
Children’s mental health services including behavioral/social/emotional screening tests during well-child visits, diagnosis, treatment, and referrals to comprehensive systems of care, and all evidence-based mental health services for children are included in this coverage. Examples of services would include comprehensive or focused ABA, residential placement and treatment, behavioral health referrals, and other therapeutic interventions for other pediatric psychiatric conditions as necessary.
Immunizations
Immunizations are to be provided according to the age-appropriate CDC immunization schedule adopted by Medicaid. The Vaccines For Children Program provides these immunization services at no charge to the child or family.
Dental
All medically necessary dental services and dental services which meet the AHCCCS Dental Periodicity Schedule are covered. Services include twice yearly maintenance visits for dental health, fluoride treatments and dental sealants, tooth extractions and restorations and treatment of infection. Individuals below the age of 21 are not limited to just emergency services. Providers must provide direct referral to a dental home as part of a comprehensive well child screening visit.
Vision
Vision services must include diagnosis and treatment for defects in vision and provide optical treatment and/or eyeglasses when appropriate.
Hearing
Hearing services must include diagnosis and treatment for defects in hearing. Treatments include surgical implants, hearing aids and other acoustical aids as indicated. Speech, language, and hearing services are related and are covered when medically necessary.
As always, don't hesitate to contact your
Mercy Care
Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our
Mercy Care
website.
Thanks for your attention to this important matter.
