EPSDT Targeted Populations Support Coordination Training Materials

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Handbook Appendices

• Appendix A - Special Medicaid Benefits for Children and Youth
• Appendix B – FFS Service and Equipment Flyer
• Appendix C - MCO Service and Equipment Flyer
• Appendix D - Services Available to Medicaid Eligible Children Under 21
  • Spanish
  • Vietnamese
• Appendix E - Medicaid Services Chart 
• Appendix F - MCO Comparison Chart
• Appendix G - EPSDT Personal Care Services vs. Home Health and PCS Rule Information
• Appendix H - EPSDT Support Coordination Fact Sheet
  • Spanish
  • Vietnamese
• Appendix I - Waiver Fact Sheets (ROW, NOW, CC, SW)  
• Local Governing Entity (LGE)
• Appendix J-1 - LGE Directory
  • Spanish
  • Vietnamese
• Appendix J-2 - LGE Regional EPSDT Specialists
  • Spanish
  • Vietnamese
• Appendix J-3 - LGE Community Behavioral Health Services
  • Spanish
  • Vietnamese
• Appendix K  - EPSDT Support Coordination FOC (Sample)
• Appendix L  - EPSDT Support Coordination Blank CPOC
• Appendix M  - Authorized Representative Form
  • Spanish
  • Vietnamese
• Appendix N - Non-legal Custodian Affidavit
  • Spanish
  • Vietnamese
• Appendix O - Rights and Responsibilities BHSF-RF-05-003
  • Spanish
  • Vietnamese
• Appendix P  - Appeal Brochure
• Appendix Q  - Complaint Form
  • Spanish
  • Vietnamese
• Appendix R - Managed Care Complaints
  • Spanish
  • Vietnamese
• Appendix S – Voluntary Opt-In to Managed Care for Chisholm Class Members
  • Spanish
  • Vietnamese
• Appendix T - Choice of Provider Form
  • Spanish
  • Vietnamese
• Appendix U - Review of Possible Eligibility Request
  • Spanish
  • Vietnamese

Handbook Appendices for Support Coordinator Use

Referral Forms

• Appendix V-1 - Referral to Provider
• Appendix V-2 - Referral to PAL

EPSDT Quarterly Report Forms

• Appendix W-1 - Checklist for EPSDT Quarterly Report
• Appendix W-2 - EPSDT Quarterly Report of Revised CPOCs
• Appendix W-3 - Record Review
• Appendix W-4 - Training Log

Contacts for Support Coordinators

• Appendix X-1 - Contact Info for EPSDT SCA
• Appendix X-2 - MCO Contacts for EPSDT SCA

CPOC + Service Logs

• Appendix Y-1 - CPOC Components
• Appendix Y-2 - CPOC Instructions
• Appendix Y-3 – Service Logs and Tracking Required Actions

CPOC Checklists

• Appendix Z-1 - CPOC Initial and Special Needs Checklist
• Appendix Z-2 - CPOC Monitoring Checklist

Timelines    

• Appendix AA-1 - Beneficiary
• Appendix AA-2 - PA Tracking

Prior Authorization

• Appendix BB-1 - PA Request Forms and Physician Forms
• Appendix BB-2 - Sample PA Notices
• Appendix BB-3 - Sample PAL Notices
• Appendix BB-4 - Modification of Rehab Services PA Tracking/PAL Referral
• Appendix BB-5 - MCO PCS and EHH PA Time Frames
• Appendix BB-6 - MCO PAL Flow Chart
• Appendix BB-7 – EPSDT-PCS FAQ and Guide to Provider Locator Tools

 

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2024 EPSDT SC Training Recording  

 

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