​PROVIDER MANUAL

 

  
  
  
  
Title PageMISSION & GOAL OF THE PROGRAM12021
Section 1INTRODUCTION: MARYLAND HEALTHY KIDS/EPSDT PROGRAM1.02021
AOverview1.12021
BHealthy Kids Program Administration1.22021
CProvider Certification & Qualifications1.32021
DLocal Health Departments' Role1.42021
EManaged Care Organizations1.52021
FHealthy Kids Program Performance Improvement Standards1.62021
GHIPAA Privacy1.72021
Section 1ADDENDUM1.802021
1.1Provider Application for Certification & Participation1.812021
Section 2MARYLAND EPSDT PREVENTIVE HEALTH CARE SCHEDULE2.002020
AInitial Screening Services2.12021
BPeriodic Screening Services2.22021
CAdditional Screening Services2.32021
DHearing, Vision & Dental Screening Services2.42021
Section 2ADDENDUM: MARYLAND HEALTHY KIDS PREVENTIVE HEALTH SCHEDULE2.62020
Section 3 HEALTHY KIDS SCREENING COMPONENTS3.002017
AHealth and Developmental History3.12016
BComprehensive Physical Examination Requirement3.22016
CLaboratory Tests3.32016
DImmunizations3.42017
EHealth Education Anticipatory Guidance3.52016
Section 3CHARTS AND TABLES3.62016
Chart 1Primary Teeth Eruption3.612015
Chart 2Permanent Tooth Eruption3.622015
Table 1Girls Systolic BP by Age & Height3.642015
Table 2Boys Systolic BP by Age & Height3.652015
Table 3Dietary Fluoride Supplement Dosage Schedule3.662014
Table 4DHMH List of Disorders on the Newborn Screen3.672016
Table 5Hematocrit & Hemoglobin Values for Children3.682015
Table 6MD Elevated Blood Lead Diagnostic & Follow-up Schedule for Children3.692014
Table 7MD Department of Environment: Case Coordination Guidelines for Lead Poisoned Children3.702014
Table 8Targeted Testing & Treatment of Latent TB Infection3.712014
Table 9Tuberculin Skin Test Cut-Points by Age for Low Risk Persons3.722014
Table 10Regimens for Treatment of Latent TB Infections3.732014
Table 11Classification of Cholesterol Levels in Children and Adolescents3.742014
Section 3ADDENDUM3.752016
3.1Developmental Screening Tools3.762014
3.2Additional Evaluation & Intervention for Developmental Disorders3.772014
3.3Modified Checklist for Autism in Toddlers-Revised, with Follow up (MCHAT-R/F)3.7712015
3.4Early Hearing Detection & Intervention Guide3.782015
3.5Jaeb Visual Acuity Screener3.7812016
3.6MD WIC Program Medical Documentation Form3.82015
3.7Expert Committee Recommendations for the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity-2007-An Implementation Guide from the Childhood Obesity Action Network3.812007
Section 4ADOLESCENT PREVENTIVE HEALTH4.02016
AA. Introduction4.12016
BB. Health and Developmental History4.22015
CC. Comprehensive Physical Examination4.32015
DD. Laboratory Tests4.42016
EE. Immunizations4.52016
FHealth Education and Anticipatory Guidance4.62015
Section 4ADDENDUM4.802015
4.1HEEADSSS Psychosocial Interview4.812015
4.2Identify and Treat Adolescent Depression4.822010
4.3Patient Health Questionnaire Modified for Teens (PSC-Y)4.832015
4.4Pediatric Symptoms Checklist for Teens (PHQ-9 Modified)4.842015
4.5Informed Consent to HIV Testing (English & Spanish)4.852007
Section 5OTHER CHILD HEALTH-RELATED SERVICES5.002016
AExpanded EPSDT-Related Services5.12016
BHealthChoice Self-Referred Services5.22016
CChildren in State-Supervised Care5.32016
DOther Programs for Children5.42016
EDental Care5.52015
FPublic Mental Health System (PMHS)5.62016
Section 5ADDENDUM5.72020
5.1Maryland Uniform Consultation Referral Form5.712015
5.2School-Based Health Center Health Visit Report Form5.722015
5.3Local Infants and Toddlers Referral and Feedback Form5.732009
5.4Local Health Services Request Form5.742015
5.5Instructions for Use of Local Health Services Request Form5.752015
5.6REM Intake Application5.772015
Section 6BILLING AND ENCOUNTER DATA REPORTING6.002017
AIntroduction6.12015
BEligibility Verification6.22015
CGeneral Rules for Medical Assistance Billing6.32016
DBilling for Fluoride Varnish Application as Part of the EPSDT Preventive Care Visit6.42016
EBilling for Vaccines for Children Program6.52017
FBilling for Services in State-supervised Care6.62015
GBilling for Services to Children in Managed Care Organizations (MCOs)6.72015
HBilling for Services to Children Non in MCO (Fee-For-Service)6.82017
ICMS-1500 Billing Instructions6.92016
Section 7APPENDICES7.002016
7.1APPENDIX: PREVENTIVE CARE FORMS7.12015
7.1.1Age Specific Encounter Forms7.122014
7.1.2Body Mass Index (BMI) Calculator-Child and Teen7.132016
7.1.3WHO & CDC Growth Charts7.132014
7.1.4Medical Family History Questionnaire (English)7.142006
7.1.5Medical Family History Questionnaire (Spanish)7.152006
7.1.6Objective Hearing and Vision Testing Forms7.162016
7.2APPENDIX:RISK ASSESSMENT FORMS7.22016
7.2.1CRAFT Adolescent Substance Abuse Assessment (English)7.222019
7.2.2CRAFT Adolescent Substance Abuse Assessment (Spanish)7.2212019
7.2.3Mental Health Questionnaires (English & Spanish)7.32014
7.2.4Nutrition Questionnaires (Infant, Child, Adolescent)7.42014
7.2.5Preventive Screen Questionnaire: Lead, TB, Anemia, Cholesterol & STD/HIV (English)7.52017
7.2.6Preventive Screen Questionnaire: Lead, TB, Anemia, Cholesterol & STD/HIV (Spanish)7.512017
7.2.7SEEK Questionnaire (Abuse Assessment) (English)7.62014
7.2.8SEEK Questionnaire (Abuse Assessment) (Spanish)7.612014
7.2.9Victimization Scale (English)7.72015
7.2.10Victimization Scale (Spanish)7.712015
7.3APPENDIX: IMMUNIZATION FORMS & RESOURCES7.82017
7.3.1Maryland Immunization Certification Form7.822014
7.3.2Maryland Recommended Childhood & Adolescent Immunization Schedules7.832019
7.3.3Maryland Combination Vaccines Schedule7.842017
7.3.4Parental Delegation Form for Minors7.852015
7.3.5VFC Vaccine Inventory Form7.862015
7.3.6VFC Log of Children Receiving VFC Vaccines7.872013
7.3.7Patient Eligibility Screening Record7.882015
7.3.8VFC Program Contact Center7.892016
7.3.9VFC Vaccine Administration Record7.92017
7.3.10VFC Vaccine Return & Wastage Form7.912015
7.3.11Temperature Log for Refrigerator-Celsius7.922017
7.3.12Temperature Log for Refrigerator-Fahrenheit7.92.12017
7.3.13Temperature Log for Freezer-Celsius7.92.22017
7.3.14Temperature Log for Freezer-Fahrenheit7.92.32017
7.4APPENDIX: HEALTH EDUCATION MATERIALS7.932017
7.4.1Zika-Information-Flyer7.942017
7.4.2MDH Zika Factsheet7.94.12017
7.4.3Communicative Diseases Factsheet7.952011
7.4.4General Child Seat Use & MD Child Safety Seat Law7.962013
7.4.5My Plate7.972015
7.4.6National Safe Kids Campaign Materials-Bike7.982013
7.4.7National Safe Kids Campaign Materials-Fire7.992013
7.4.8National Safe Kids Campaign Materials-Gun7.9912013
7.4.9National Safe Kids Campaign Materials-Poison7.9922014
7.4.10National Safe Kids Campaign Materials-Water7.9932013
7.4.11CDC Tuberculosis Training Materials Order Form7.9942015
7.4.12Center for Immunization Health Education Materials Order Form7.9952014
7.4.13DHMH Office of Oral Health Printed Materials Request Form7.9962015
7.4.14HIV/AIDS Prevention Materials Order Form7.9972015
7.4.15Kids in Safety Seats Education Materials Order Form7.9982013
7.4.16Lead Poisoning Prevention Program Educational Materials Order Form7.9992008
7.4.17Maternal & Child Health Bureau Publication Order Form7.99912013
Section 8TELEPHONE DIRECTORIES8.002016
AHealthy Kids Consultants8.22017
BLocal Departments of Social Services8.32014
CLocal Domestic Violence Directory8.42014
DLocal Health Departments Administrative Care Coordination Units8.52019
ELocal Health Departments Children's Health Program (MCHP)8.62015
FLocal Health Departments Nursing Lead Contacts8.72014
GLocal Health Departments TB Control Coordinators8.82014
HLocal Protective Services8.92014
IMaryland Head Start8.912015
JMaryland Health Connection Connector Entities8.922014
KMaryland Local WIC Agencies8.932014
LMaryland VFC Contact Center8.942015
MMedicaid Administration & Billing Contacts8.952015
NMedicaid HealthChoice Managed Care Organization Resource List8.962015
OMedicaid HealthChoice Managed Care Organization Pharmacy Benefit Managers8.972014
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