Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

The Pharmacy Services Department at AmeriHealth Caritas North Carolina issues Prior Authorizations for drugs that require clinical review based on NCDHHS clinical criteria requirements and EPSDT criteria. Contact Pharmacy Provider Services at 1-866-885-1406, 24/7, 365 days a year, if you have a question about submission of a Pharmacy EPSDT Prior Authorization.

An EPSDT Pharmacy Prior Authorization can be submitted via:

• Web request under Pharmacy at www.amerihealthcaritasnc.com Opens a new window
• Faxing a completed prior authorization form to 1-877-234-4274
  • Pharmacy Request Form - Non-Covered State Medicaid Plan Services Request Form (Recipients under 21) Opens a new window (PDF)
• Calling PerformRx Provider Services at 1-866-885-1406 for verbal prior authorization requests
• Entering an Electronic Prior Authorization (ePA) via your Electronic Health Records (EHR) Platform

Providers receive a fax notifying them of the EPSDT pharmacy prior approval decision.

Using NaviNet, the EP modifier Complete Screen should be used when submitting a preventive service claim.

No, EPSDT preventive services (early and periodic screens/wellness visits) will not require prior authorization from ACNC. Prior authorization may be required for other EPSDT diagnostic and treatment products. Use our Prior Authorization Lookup tool for immediate guidance on prior authorization requirements.

Use our Prior Authorization Lookup tool for immediate guidance on prior authorization requirements and modes of submission for all prior authorization requests (including requests that will be reviewed using EPSDT criteria). Providers receive notification of prior approval decisions by fax and/or telephone call from our Utilization Management team via the provider portal. The decision will be loaded into the portal.

Having confirmed the member is under 21 years of age, claims will be identified based on the presence of third-party liability (TPL) in the member’s record. The claims identified with TPL that also meet the following criteria (A or B), will be paid by ACNC, who will then follow up with the primary carrier for payment:

1. Claims for preventive services that do not require prior authorization
2. Claims with a prior authorization approved under EPSDT on file for services that require prior authorization

EPSDT claims will be paid in a timely and accurate manner. Medical payment cycles run every Monday, Wednesday and Friday. Pharmacy payment cycles run every four days.

Log into NaviNet and see the Claims Status Inquiry link under Workflows on the left-hand side, or call Provider Services at 1-888-738-0004.

Log into NaviNet and see the Forms and Dashboards link under Workflows on the left-hand side to select Grievance and Appeals. Go to Complete a Grievance. Then fill out the grievance form and submit. Upon submission, write down the Document ID # shown and call Provider Services at 1-888-738-0004 for inquiries.